https://orcid.org/0000-0002-6742-1016
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Gabor Erdoes, Milan Milojevic, Bianca Rocca, Andreas Koster, Clinical guidelines for a dry land: challenges in developing recommendations for DOAC management in emergent cardiac surgery, European Journal of Cardio-Thoracic Surgery, Volume 67, Issue 2, February 2025, ezaf015, https://doi.org/10.1093/ejcts/ezaf015
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Clinical practice guidelines form the cornerstone of optimal patient management and substantially rely on evidence-based medicine, with updated research and rigorous methodology serving as their foundation [1, 2]. In 2024, two major EACTS guidelines on perioperative care in adult cardiac surgery underwent comprehensive updates [3, 4]. These updates also addressed one of the most pivotal advancements in the prevention and management of cardioembolic diseases in modern cardiac surgery: the implementation of direct oral anticoagulants (DOACs) in daily cardiac surgery practice.
Since their widespread adoption between 2010 and 2015, DOACs have significantly impacted the field of cardiac surgery, presenting challenges akin to a tsunami [5]. Initially, the cardiac surgery community was unprepared to manage patients receiving this novel therapy. However, as the current guidelines illustrate, the field has gradually adapted to managing surgical patients treated with these anticoagulants, considering their major pharmacological aspects and the availability of calibrated assays to measure drug levels. These monitoring assays have confirmed that in patients with severe renal impairment, residual therapeutic drug concentrations can persist even 48 h after discontinuation, depending on the drug’s classification and half-life. Additionally, critical thresholds for residual drug levels have been defined to ensure safety before elective cardiac surgery [3], although these thresholds require further clinical validation in the context of cardiac surgery.
