Table 7.

European Heart Rhythm Association recommendations for timing of treatment interruption of approved direct oral anticoagulants prior to elective surgery according to renal function and surgery bleeding risk

Direct oral anticoagulant	Dabigatran		Apixaban or rivaroxaban
Surgery bleeding risk	Lowa	Highb	Lowa	Highb
Normal renal function (CrCl ≥80 mL/min), hours	≥24	≥48	≥24	≥48
Mild renal impairment (CrCl 50–80 mL/min), hours	≥36	≥72	≥24	≥48
Moderate renal impairment (CrCl 30–50 mL/min), hours	≥48	≥96	≥24	≥48
Severe renal impairment (CrCl 15–30 mL/min), hours	Dabigatran contraindicated		≥36	≥48
Renal failure (CrCl <15 mL/min)	Dabigatran contraindicated		Apixaban and rivaroxaban not recommended

Notes:

^aSurgeries/procedures with low risk of bleeding include: endoscopy with biopsy, prostate or bladder biopsy, electrophysiological study or radiofrequency catheter ablation for supraventricular tachycardia, angiography, and pacemaker or implantable cardioverter defibrillator implantation;

^bsurgeries/procedures with high risk of bleeding include: complex left-sided ablation, spinal or epidural anesthesia, lumbar diagnostic puncture, thoracic surgery, abdominal surgery, major orthopedic surgery, liver biopsy, transurethral prostate resection, and kidney biopsy. Adapted from Heidbuchel H, Verhamme P, Alings M, et al. European Heart Rhythm Association practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013, 15, 5, 625–651, by permission of Oxford University Press.⁵³

Abbreviation: CrCl, creatinine clearance.