Non-Cochrane · intervention · PM42027304
Continuous vs interrupted direct oral anticoagulants for minimal bleeding-risk surgical procedures-a systematic review and meta-analysis.
Xiang Alexander, Popatia Shakil, Sadafi Sarah Lopes, et al. · Research and practice in thrombosis and haemostasis · 2026 · PubMed · doi:10.1016/j.rpth.2026.103419
Findings
36 findings
| Population | ||||
|---|---|---|---|---|
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Total surgical complications Discharge · Subgroup by study design: randomized trials | OR 1.03 [0.59, 1.81] GRADE not reported 5 studies · 1386 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Thrombotic events (arterial or venous thromboembolism) All time points · All studies | OR 0.54 [0.33, 0.87] Very low Downgraded: risk of bias, inconsistency 16 studies · 5598 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Thrombotic events at 30 days 30 days · All studies | OR 0.57 [0.28, 1.16] Very low Downgraded: risk of bias, inconsistency 9 studies · 3834 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Thrombotic events (arterial or venous thromboembolism) All time points · Subgroup by study design: randomized trials | OR 0.53 [0.17, 1.64] GRADE not reported 8 studies · 2926 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Minor bleeding events All time points · Subgroup by study design: randomized trials | OR 1.02 [0.71, 1.45] GRADE not reported 6 studies · 2682 participants |
| Patients on direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Minor bleeding events All end points · Prospective nonrandomized studies | OR 0.99 [0.62, 1.60] GRADE not reported Studies not reported |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Total surgical complications Discharge · All studies | OR 1.05 [0.71, 1.54] Low Downgraded: risk of bias 9 studies · 2021 participants |
| Patients on direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Thrombotic events (arterial or venous thromboembolism composite) All end points · Retrospective nonrandomized studies | OR 0.56 [0.23, 1.38] GRADE not reported Studies not reported |
| Patients on direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Thrombotic events (arterial or venous thromboembolism composite) All end points · Prospective nonrandomized studies | OR 0.50 [0.27, 0.92] GRADE not reported Studies not reported |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Stroke or transient ischemic attack (post hoc) All time points · All studies (post hoc) | OR 0.73 [0.26, 2.04] GRADE not reported Studies not reported |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Mortality Discharge · All studies | OR 0.33 [0.08, 1.41] Low Downgraded: risk of bias 4 studies · 1672 participants |
| Patients on direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Minor bleeding events All end points · Retrospective nonrandomized studies | OR 0.74 [0.38, 1.45] GRADE not reported Studies not reported |
| Patients on direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Major bleeding events All end points · Retrospective nonrandomized studies | OR 0.43 [0.15, 1.19] GRADE not reported Studies not reported |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Minor bleeding events All time points · All studies | OR 0.93 [0.69, 1.24] Low Downgraded: risk of bias 12 studies · 4185 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Major bleeding events All time points · All studies | OR 0.57 [0.37, 0.87] Low Downgraded: risk of bias 19 studies · 6172 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | All bleeding events All time points · Subgroup by study design: nonrandomized studies | OR 0.56 [0.38, 0.81] GRADE not reported 12 studies · 3112 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Major bleeding events All time points · Subgroup by study design: randomized trials | OR 0.82 [0.42, 1.61] GRADE not reported 8 studies · 3109 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | All bleeding events All time points · Subgroup by study design: randomized trials | OR 0.96 [0.7, 1.32] GRADE not reported 8 studies · 3109 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | All bleeding events All time points · All studies | OR 0.79 [0.62, 1.01] Low Downgraded: risk of bias 20 studies · 7001 participants |
| Patients on direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Major bleeding events All end points · Prospective nonrandomized studies | OR 0.65 [0.26, 1.65] GRADE not reported Studies not reported |
| Patients taking DOACs undergoing catheter ablation | Continuous DOAC regimen | Interrupted DOAC regimen | Major bleeding events All time points · Subgroup by procedure type: ablation | OR 0.7 [0.37, 1.34] GRADE not reported 10 studies · 3270 participants |
| Patients taking DOACs undergoing catheter ablation | Continuous DOAC regimen | Interrupted DOAC regimen | Thrombotic events (arterial or venous thromboembolism) All time points · Subgroup by procedure type: ablation | OR 0.53 [0.34, 0.84] GRADE not reported 13 studies · 4739 participants |
| Patients taking DOACs undergoing catheter ablation | Continuous DOAC regimen | Interrupted DOAC regimen | Minor bleeding events All time points · Subgroup by procedure type: ablation | OR 0.98 [0.69, 1.39] GRADE not reported 8 studies · 2611 participants |
| Patients on direct oral anticoagulants undergoing minimal bleeding-risk procedures (pacemaker or device insertion) | Continuous DOAC regimen | Interrupted DOAC regimen | Minor bleeding events All end points · Type of procedure: pacemaker insertion | OR 1.12 [0.47, 2.68] GRADE not reported 1 study · 662 participants |
| Patients taking DOACs undergoing pacemaker or cardiac device insertion | Continuous DOAC regimen | Interrupted DOAC regimen | Thrombotic events (arterial or venous thromboembolism) All time points · Subgroup by procedure type: pacemaker or device insertion | OR 0.41 [0.06, 2.95] GRADE not reported 4 studies · 2149 participants |
| Patients taking DOACs undergoing pacemaker or cardiac device insertion | Continuous DOAC regimen | Interrupted DOAC regimen | Major bleeding events All time points · Subgroup by procedure type: pacemaker or device insertion | OR 0.57 [0.18, 1.76] GRADE not reported 4 studies · 1397 participants |
| Patients taking DOACs undergoing minor dental procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Minor bleeding events All time points · Subgroup by procedure type: dental procedures | OR 1.44 [0.11, 18.47] GRADE not reported Studies not reported |
| Patients taking DOACs undergoing minor dental procedures | Continuous DOAC regimen | Interrupted DOAC regimen | Major bleeding events All time points · Subgroup by procedure type: dental procedures | OR 1.02 [0.08, 12.7] GRADE not reported Studies not reported |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | DOAC interrupted the morning of the procedure (day of) | Major bleeding events All time points · Subgroup by interruption interval: day of procedure | OR 0.56 [0.27, 1.19] GRADE not reported 5 studies · 2256 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | DOAC interrupted the morning of the procedure (day of) | Minor bleeding events All time points · Subgroup by interruption interval: day of procedure | OR 1.01 [0.68, 1.49] GRADE not reported 4 studies · 1923 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | DOAC interrupted the morning of the procedure (day of) | Thrombotic events (arterial or venous thromboembolism) All time points · Subgroup by interruption interval: day of procedure | OR 0.51 [0.29, 0.93] GRADE not reported 6 studies · 2196 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | DOAC interrupted 24 hours before the procedure | Minor bleeding events All time points · Subgroup by interruption interval: 24 hours | OR 0.72 [0.43, 1.2] GRADE not reported 6 studies · 1557 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | DOAC interrupted 24 hours before the procedure | Major bleeding events All time points · Subgroup by interruption interval: 24 hours | OR 0.66 [0.27, 1.6] GRADE not reported 7 studies · 1935 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | DOAC interrupted 24 hours before the procedure | Thrombotic events (arterial or venous thromboembolism) All time points · Subgroup by interruption interval: 24 hours | OR 0.68 [0.24, 1.91] GRADE not reported 8 studies · 2174 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | DOAC interrupted 48 hours before the procedure | Major bleeding events All time points · Subgroup by interruption interval: 48 hours | OR 0.48 [0.17, 1.36] GRADE not reported 3 studies · 1302 participants |
| Patients taking direct oral anticoagulants undergoing minimal bleeding-risk procedures | Continuous DOAC regimen | DOAC interrupted 48 hours before the procedure | Thrombotic events (arterial or venous thromboembolism) All time points · Subgroup by interruption interval: 48 hours | OR 0.41 [0.17, 0.96] GRADE not reported 3 studies · 3278 participants |
Included primary studies 25
Open in Studies| Study | Year | Also included by | Outcomes it informs here | Trial data |
|---|---|---|---|---|
| Ando 2019 Differences in prothrombotic response between the uninterrupted and interrupted apixaban therapies in patients undergoing cryoballoon… PMID:30840130 | 2019 | this review only | not stated | not extracted yet |
| Aoyama 2019 Feasibility of Uninterrupted Direct Oral Anticoagulants with Temporary Switching to Dabigatran ("Dabigatran Bridge") for Catheter Ablation… PMID:31735780 | 2019 | this review only | not stated | not extracted yet |
| Birnie 2018 Continued vs. interrupted direct oral anticoagulants at the time of device surgery, in patients with moderate to high risk of arterial… PMID:30462279 | 2018 | this review only | not stated | not extracted yet |
| Black-Maier 2017 Oral anticoagulation management in patients with atrial fibrillation undergoing cardiac implantable electronic device implantation. PMID:28543401 | 2017 | this review only | not stated | not extracted yet |
| Cheung 2019 Phacoemulsification cataract surgery in patients receiving novel oral anticoagulant medications. PMID:29435797 | 2019 | this review only | not stated | not extracted yet |
| Creta 2023 DOACs vs Vitamin K Antagonists During Cardiac Rhythm Device Surgery: A Multicenter Propensity-Matched Study. PMID:37897463 | 2024 | this review only | not stated | not extracted yet |
| Gjermeni 2023 DOI:10.1161/circ.140.suppl_1.16038 | NR | this review only | not stated | not extracted yet |
| Izzetti 2024 Direct Oral Anticoagulants and Bleeding Management Following Tooth Extractions-A Prospective Cohort Study. PMID:39329845 | 2024 | this review only | not stated | not extracted yet |
| Kwak 2019 Bleeding related to dental treatment in patients taking novel oral anticoagulants (NOACs): a retrospective study. PMID:29696419 | 2019 | this review only | not stated | not extracted yet |
| Lababidi 2018 Assessing an oral surgery specific protocol for patients on direct oral anticoagulants: a retrospective controlled cohort study. PMID:29653869 | 2018 | this review only | not stated | not extracted yet |
| Miller 2018 Direct oral anticoagulants: A retrospective study of bleeding, behavior, and documentation. PMID:29480605 | 2018 | this review only | not stated | not extracted yet |
| Muller 2016 Impact of periprocedural anticoagulation strategy on the incidence of new-onset silent cerebral events after radiofrequency catheter… PMID:27020439 | 2016 | this review only | not stated | not extracted yet |
| Nagao 2019 Impact of periprocedural anticoagulation therapy on the incidence of silent stroke after atrial fibrillation ablation in patients… PMID:30376051 | 2019 | this review only | not stated | not extracted yet |
| Nakamura 2018 Papillary cystadenocarcinoma of the pancreas with report of two cases. PMID:13812018 | 1959 | this review only | not stated | not extracted yet |
| Nakamura 2018 Impact of hydronephrosis on outcome of stage IIIB cervical cancer patients with disease limited to the pelvis, treated with radiation and… PMID:20181381 | 2010 | this review only | not stated | not extracted yet |
| Nakamura 2019 (cryoballoon dabigatran) Clinical comparative study regarding interrupted and uninterrupted dabigatran therapy during perioperative periods of cryoballoon ablation… PMID:31029455 | 2019 | this review only | not stated | not extracted yet |
| Nakamura 2019 (Europace RCT) Uninterrupted vs. interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: a prospective… PMID:29982562 | 2019 | this review only | not stated | not extracted yet |
| Osawa 2022 Effects of uninterrupted dabigatran on the intensity of anticoagulation during atrial fibrillation ablation. PMID:35222751 | 2022 | this review only | not stated | not extracted yet |
| Petzl 2021 Cerebral thromboembolic risk in atrial fibrillation ablation: a direct comparison of vitamin K antagonists versus non-vitamin K-dependent… PMID:32144677 | 2021 | this review only | not stated | not extracted yet |
| Reynolds 2018 A Prospective Randomized Trial of Apixaban Dosing During Atrial Fibrillation Ablation: The AEIOU Trial. PMID:29798783 | 2018 | this review only | not stated | not extracted yet |
| Ricciardi 2018 Interrupted versus uninterrupted novel oral anticoagulant peri-implantation of cardiac device: A single-center randomized prospective… PMID:30132926 | 2018 | this review only | not stated | not extracted yet |
| Sheikh 2021 Comparison of temporary interruption with continuation of direct oral anticoagulants for low bleeding risk procedures. PMID:33906063 | 2021 | this review only | not stated | not extracted yet |
| van der Wall 2021 Low bleeding and thromboembolic risk with continued dabigatran during cardiovascular interventions: the GLORIA-AF study. PMID:34120814 | 2021 | this review only | not stated | not extracted yet |
| Yamaji 2019 Activated clotting time on the day of atrial fibrillation ablation for minimally interrupted and uninterrupted direct oral anticoagulation… PMID:31701593 | 2019 | this review only | not stated | not extracted yet |
| Yu 2019 When is it appropriate to stop non-vitamin K antagonist oral anticoagulants before catheter ablation of atrial fibrillation? A multicentre… PMID:30590600 | 2019 | this review only | not stated | not extracted yet |
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Patients on direct oral anticoagulants undergoing minimal bleeding-risk procedures (cardiac device implantation, catheter ablation, radial coronary angiography, minor dermatological, cataract or minor dental procedures) | Patients on DOACs undergoing ablation (n=13 studies), pacemaker insertion (n=4), dental procedures (n=4), cataract and mixed procedures; N=8663 |
| Intervention | Continuous perioperative DOAC regimen | Continuous DOAC regimen (n=24 studies) |
| Comparison | Interrupted perioperative DOAC regimen | Interrupted DOAC regimen: morning of procedure (n=6), 24 hours (n=9), 48 hours (n=5), 72 hours (n=1) |
| Outcomes | Arterial or venous thromboembolism; major and minor bleeding; surgical complications; mortality; hospital length of stay | Thrombotic events (16 studies); all bleeding (20); major bleeding (19); minor bleeding (12); total complications (9); mortality (4) |
| Study designs | Prospective cohort, retrospective cohort studies and RCTs | 8 RCTs, 8 prospective cohort studies, 8 retrospective cohort studies |
| Timing | Any follow-up duration | Total complications and mortality assessed at discharge; thrombotic events at all end points and at 30 days |
AMSTAR 2 items
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | Yes | yes |
| 2Protocol established before the reviewcritical | Yes | Yes | yes |
| 3Choice of study designs explained | No | No | yes |
| 4Comprehensive literature searchcritical | Partial Yes | Partial Yes | yes |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | Yes | Yes | yes |
| 7List of excluded studies with reasonscritical | No | No | yes |
| 8Included studies described in detail | Partial Yes | Partial Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | RCT: Yes · NRSI: Yes | NRSI: Yes · RCT: Yes | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: Yes · NRSI: Partial Yes | NRSI: No · RCT: Yes | no |
| 12Impact of risk of bias on the pooled results | Yes | Yes | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | Yes | Yes | yes |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | Low | Critically Low | no |