1. Introduction:
Bleeding is a major concern in cardiac surgery with possibly requiring blood transfusions and re-exploration, both identified as independent risk factors for increased perioperative morbidity and mortality, especially when intervening in an emergency setting.1–4 The risk of bleeding is amplified in patients on oral anticoagulants and antiplatelet medications that have become a cornerstone in the treatment of conditions, such as strokes, coronary artery disease (CAD), atrial fibrillation (AF), peripheral vascular disease, and deep venous thrombosis (DVT).5,6
Over 6-million patients are on anticoagulants and this number is expected to rise to 12-million in 2030, mainly due to the aging population with an increased prevalence of AF, and to the earlier diagnosis of occult AF with use of implantable loop recorders.5,7 Direct oral anticoagulants (DOACs), such as direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban, edoxaban, betrixaban), have become first-line choices in the treatment and prevention of thromboembolism as well as stroke prophylaxis in patients with AF.6Randomized trials have demonstrated the superiority of dabigatran (RE-LY trial) and apixaban (ARISTOTLE trial) over the traditionally used vitamin-K antagonists (VKAs) in thromboembolic stroke prevention.8,9 In addition, DOACs have several other advantages including, rapid onset in their action limiting the need for bridging, less drug-drug and drug-food interactions, and easier use with reduction of blood level monitoring.
Anticoagulants also include antiplatelet medications, such as aspirin (ASA) and the P2Y12 receptor antagonists (clopidogrel, ticagrelor and prasugrel), used for the treatment of CAD, acute coronary syndrome (ACS) and following percutaneous coronary interventions (PCI). Patients frequently receive dual antiplatelet medications consisting of ASA and a P2Y12 receptor antagonist, shown to improve survival and reduce in-stent thrombosis.10
The above landscape has made operating on patients receiving oral anticoagulants and antiplatelet medications inevitable and an unfortunate reality. We sought to review available literature with regards to guidelines on management of patients receiving above medications who require emergency cardiac operations. Informed consent and institutional review board approval were not required and were waived for the purpose of this study.