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.