Abstract WP98: Variability of Perioperative Anticoagulation Strategies in Patients With Atrial Fibrillation

Introduction: In patients with atrial fibrillation (AFib) whose anticoagulation (AC) requires being held prior to non-emergent surgery, ischemic stroke is an unfortunately familiar event. Current practices in the holding of anticoagulation pre-op and the use of bridging therapy are heterogeneous, the guidelines for which are often underutilized. Methodology: We surveyed cardiologists, general practitioners and surgical specialists across a single large academic-based healthcare institution regarding periprocedural AC practices in patients with AFib. Data were organized by provider type and experience. Chi-square, Fisher exact, and Student's t-tests were used to analyze differences in anticoagulation practices. Results: Of 2,604 surveys emailed, 14 cardiologist, 53 general practitioners and 70 procedural/surgical specialists participated. Average number of days surgical specialists required holding AC were 2.6 (SD = 1.2) for direct oral anticoagulant (DOAC) and 4.6 (SD=1.6) for warfarin. INR goal averaged 1.6 (SD 0.3). Surgical specialists required bridging therapy for DOAC significantly less often than they did for warfarin, 15.5% vs 44.3%, X 2 = 14.0, p < 0.001. Timing of DOAC held and warfarin held did not differ between attendings and trainees, nor did threshold goal INR. In contrast, practices between non-surgical specialists widely differed. Cardiologists trended roughly 4 times less likely than general practitioners to prescribe bridging therapy while DOAC was held, X 2 = 3.3, p = 0.06, yet they also trended toward prescribing bridging therapy more often for patients who had history of ischemic stroke. Significantly, attendings were 5 times less likely than residents to prescribe bridging therapy for DOACs and 3x times less likely to do so for warfarin, X 2 = 14.9, p = 0.0001 and X 2 = 5.5, p = 0.01, respectively. Conclusion: Our data indicate that significant differences exist in pre-op anticoagulation recommendations across provider type as well as training level. These differences are most stark in the use of bridging therapy while anticoagulation is held. Surgeons demonstrated more consistency in their anticoagulation strategies than did non-surgical providers.