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Perioperative DOAC Stopping Rules — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyPerioperative DOAC Stopping RulesEECC

A 60-year-old man with AF and a CHA₂DS₂-VA score of 4 on rivaroxaban has a scheduled colonoscopy with polypectomy (high bleeding risk procedure). When should rivaroxaban be stopped and restarted?

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Correct answer: A — Stop rivaroxaban ≥48 hours before a high-bleeding-risk procedure (≥24 hours for low-risk); restart 48-72 hours post-procedure when haemostasis is secured — no bridging with LMWH is needed for DOACs

Perioperative DOAC management follows standardised protocols based on bleeding risk and renal function. The 2024 ESC AF Guidelines and EHRA practical guide recommend: (1) Low bleeding risk procedures: stop DOAC ≥24 hours before; (2) High bleeding risk procedures: stop DOAC ≥48 hours before; (3) Adjust for renal function (longer for dabigatran with CKD due to 80% renal clearance); (4) NO bridging with LMWH — this is a critical difference from warfarin management; DOACs have short half-lives (5-17 hours), so drug levels rapidly decline after cessation, making bridging unnecessary and potentially harmful (PERIOP-2 trial confirmed low thrombotic risk with simple DOAC interruption); (5) Restart: 24 hours post-low-risk procedure; 48-72 hours post-high-risk procedure. Timing should be confirmed with the proceduralist.

Reference: ESC (2024): AF Guidelines; EHRA Practical Guide