Temporary Discontinuation and Restarting of Oral Anticoagulants for Neurological and Cardiac Indications.

Abstract

Approximately 1 million people in Germany are under treatment with an oral anticoagulant (OAC) for the primary or secondary prophylaxis of arterial and venous thromboembolic disease. Each year, 12-20% of them undergo an invasive procedure or operation. The temporary discontinuation and restarting of OAC for comorbid conditions, complications, and invasive procedures should be designed both to reduce thromboembolic events and to avoid hemorrhagic complications. In this narrative review, we present the state of the evidence and the current guideline recommendations, particularly for cardiological and neurological/neurosurgical indications. In periprocedural discontinuation of OAC, the risk of hemorrhage is higher if unnecessary heparin bridging is performed, or if the chosen pausing interval is too short. On the other hand, the thromboembolic risk is higher while the patient is not taking OAC. In the case of invasive procedures or complications under OAC, the individual hemorrhagic and thromboembolic risks should be assessed, and the timing of discontinuation and reintroduction of the OAC should be decided upon in view of the potential clinical consequences. Prior thromboembolic events and hemorrhages should be taken into account, as well as the patient's age, kidney function, accompanying illnesses, and any co-medication with antiplatelet agents. For ischemic stroke, recent studies indicate that the early (re-)introduction of OAC is advantageous. Whether and when patients who have sustained an intracranial hemorrhage should be given OAC remains unclear and is a current topic of investigation. A standardized approach to the periprocedural administration of OAC and the management of complications should be agreed upon by interdisciplinary consensus in each clinical institution.