Direct Oral Anticoagulant Treatment for Atherosclerosis-Induced Aortic Mural Thrombus in an Elderly Male With Aspirin Resistance.

Aortic mural thrombus is associated with atherosclerosis in a vast majority of cases and could result in multiple organ damage, leading to higher morbidity and mortality rates. Although aspirin could be effective for primary prevention in atherosclerosis-induced aortic mural thrombus, aspirin resistance, which refers to the inadequate response to aspirin therapy, allows the progression of thrombus. Classically, warfarin could be an effective treatment for thromboembolic diseases, while in recent years, direct oral anticoagulants (DOACs) have shown superior safety and efficacy, particularly in elderly patients. This report presents the case of an elderly male with chronic aortic mural thrombi due to atherosclerosis and aspirin resistance who achieved favorable outcomes following treatment with DOACs. DOACs could be a possible option for managing aortic mural thrombus with aspirin resistance.

Effectiveness of Direct Oral Anticoagulants and Vitamin K Antagonists in Preventing Stroke in Patients With Atrial Fibrillation and Liver Cirrhosis: A Systematic Review and Meta-Analysis.

Patients with atrial fibrillation and concurrent liver cirrhosis have been excluded from major clinical trials evaluating direct oral anticoagulants (DOACs) due to safety concerns. This has led to uncertainty regarding the optimal anticoagulant therapy in this population at high risk of thromboembolic events. We conducted a systematic review and meta-analysis to compare the effectiveness and safety of DOACs versus vitamin K antagonists (VKAs) in patients with atrial fibrillation and liver cirrhosis. Databases including Embase, MEDLINE/PubMed, and Web of Science were searched for relevant studies. The primary effectiveness outcome was stroke or systemic embolism, and the safety outcome was major bleeding events. A total of 10 studies were included in the meta-analysis. Compared to VKAs, the use of DOACs was associated with a significantly lower risk of stroke or systemic embolism (RR: 0.78, 95% CI: 0.65-0.92, p=0.005). The risk of all-cause mortality was comparable between the two groups (RR: 0.89, 95% CI: 0.74-1.07, p=0.23). Notably, DOACs demonstrated a significantly lower risk of major bleeding events (RR: 0.67, 95% CI: 0.61-0.73, p<0.01) compared to VKAs. This meta-analysis suggests that DOACs may be a favorable alternative to VKAs for the prevention of thromboembolic events in patients with atrial fibrillation and liver cirrhosis, with a lower risk of stroke or systemic embolism and major bleeding. However, further research is needed to establish optimal dosing strategies and assess the safety and efficacy of DOACs in patients with advanced liver disease.

Paravertebral Block for Multiple Rib Fractures in an Anticoagulated Trauma Patient.

This case report presents the complex analgesia management of a 52-year-old male with a significant medical history including atrial fibrillation treated with apixaban, essential trigeminal neuralgia, non-ischemic cardiomyopathy, and chronic systolic heart failure. The patient experienced a loss of control while riding a motorized bicycle, resulting in a fall and head injury with no loss of consciousness. Upon admission, he tested positive for ethanol, cannabinoids, and oxycodone. The physical exam was significant for right cephalohematoma and right elbow hematoma. Imaging revealed multiple injuries, including right rib fractures (T3-12) with hemothorax. Right paravertebral catheters were placed in the intensive care unit (ICU).

Dabigatran Etexilate Related Unilateral Adrenal Hemorrhage.

A 63-year-old male presented to our clinic with computed tomography data of a large tumor of the left adrenal gland. The formation is highly suspicious for malignancy with central necrosis and hemorrhage, and a total size of 197/183/201 mm. Due to elevated D-dimer values of 7.17 mg/l (reference range <0.5 mg/l), treatment with dabigatran etexilate 2x150 mg was prescribed following a cardiology consult. On the third day of therapy, the patient noticed a large swelling in the left abdominal flank, which caused discomfort. No additional symptoms were reported. No previous abdominal surgical interventions or trauma were reported. Following a thorough physical examination, the patient was referred for a computer tomography that reported a diagnosis of a tumor of the left adrenal gland. Due to the size of the neoplasm, the suspicion of malignancy, compression of adjacent structures, and significant anemia with an Hb of 112 g/L, operative treatment was chosen as the best treatment modality. The mass was reported as a large organizing adrenal hematoma with no suspicion of malignancy on histology. Following a review of available literature, no other cases of unilateral adrenal hematoma with a size of 201x197 mm, following oral anticoagulant therapy with dabigatran etexilate, without any prior surgery or trauma have been reported. Most clinical cases report bilateral adrenal hemorrhage during the postoperative period, following prophylaxis with heparin and the development of heparin-induced thrombocytopenia. The patient underwent operative treatment, after which the patient recovered normally and was discharged from the clinic without complications.

High-Dose Immunoglobulin Therapy for Multiple Thromboembolism in Persisting Heparin-Induced Thrombocytopenia.

This report presents a case of an 81-year-old male with acute respiratory distress syndrome secondary to aspiration pneumonia who developed heparin-induced thrombocytopenia (HIT). His platelet count remained persistently low despite discontinuing unfractionated heparin and initiating intravenous argatroban. Multiple thromboembolisms, including a new aortic mural thrombus in the descending aorta, were observed on contrast-enhanced computed tomography (CT), resulting in a diagnosis of autoimmune HIT (aHIT). Subsequent high-dose intravenous immunoglobulin (IVIG) therapy substantially improved the platelet count and resolved thromboembolisms. This case is notable owing to the improvement of aHIT complicated by multiple thromboembolisms, including an aortic mural thrombus, following high-dose IVIG therapy. In recent years, a growing number of reports have documented the effectiveness of high-dose IVIG therapy for aHIT. However, reports on whether high-dose IVIG therapy could improve an aortic mural thrombus complicating aHIT are lacking. The successful use of high-dose IVIG therapy in the current case highlights its potential efficacy in treating aHIT complicated by multiple thromboembolisms. Further studies are required to clarify the role of IVIG in the management of aHIT with thromboembolism.

Single-Center Outcomes of WATCHMAN™ Implantation with Comparison to Oral Anticoagulant and Dual Antiplatelet Therapy.

Background The WATCHMAN™ device is a Food and Drug Administration (FDA)-approved device that reduces the risk of stroke from atrial fibrillation (AF) in those who have a contraindication to taking oral anticoagulation. A key aspect of this device implantation is the choice of medical therapy in the months after device implantation with Vitamin K antagonist oral anticoagulants (OAC) being the mainstay of therapy but dual antiplatelet therapy (DAPT) poses as a potential alternative to patients who have a contraindication to OAC use. Methods Our single-center study retroactively followed 150 patients post-WATCHMAN™ implantation and evaluated outcomes at 12 months post-implantation in two cohorts, those treated with OAC or DAPT. Our results were obtained via chart review of a single-center electronic medical records system. Results In our study, 67.33% of study patients were males and 49.33% were on OAC compared to 36.00% that were on DAPT. Ten patients were not able to undergo device implantation. With this analysis, we found similarly low rates of complications such as stroke and device-associated thrombosis (DAT) in both groups. Our DAPT cohort did have a higher number of gastrointestinal (GI) bleeding but this was not significant in our analysis. Discussion Our study compares to larger trials that show similar outcomes between OAC and DAPT post-implantation of the WATCHMAN™ device. The increased number of GI bleeding in our DAPT cohort could be the result of the underlying advanced age and comorbidity of that patient cohort. Conclusion Our results suggest that DAPT is a safe alternative to OAC for patients undergoing WATCHMAN™ implantation.

Appropriateness of Prescribing Rivaroxaban at King Khalid University Hospital Riyadh.

Background and aim Warfarin is recognized as a first-line treatment for different coagulopathy conditions; however, guidelines also encourage the use of rivaroxaban as an alternative option. The recent approval of the novel oral anticoagulants (NOACs) has led to swift changes in anticoagulant prescribing practices. This study aimed to review rivaroxaban prescribing patterns in adult patients in a large tertiary care setting in the Kingdom of Saudi Arabia (KSA). Materials and methods A retrospective cross-sectional study was conducted from January 2019 to September 2020 at King Khalid University Hospital, Riyadh, KSA. Data was collected from the patient's medical record. Data analysis was performed with the Statistical Package for the Social Sciences (SPSS) IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Results A total of 309 patients were included in this study. Rivaroxaban use for non-valvular atrial fibrillation (NVAF) was relatively higher than deep venous thrombosis/pulmonary embolism (DVT/PE). 45% of the patients had NVAF, followed by DVT/PE (26%), and DVT/PE prophylaxis (25%). Fifty-six patients, (18%) received an inappropriate dose of rivaroxaban for NVAF. Conclusion This study found a relatively high percentage of inappropriate rivaroxaban prescribing, predominantly because of inappropriate dosing, which can potentially increase medication-related events. The use of rivaroxaban should be monitored to increase the appropriateness of therapy and improve patient safety.

Acute Mesenteric Ischemia in a Chronically Anticoagulated Patient With Atrial Fibrillation: Anticoagulation Reversal, Management and Preventing Recurrence.

Acute mesenteric ischemia (AMI) is caused by an interruption of the blood supply to the small intestine. Atrial fibrillation is a common cause of thromboembolic AMI. Patients taking direct oral anticoagulants (DOACs) for anticoagulation in atrial fibrillation are prone to anticoagulation failure and can present with thromboembolism. We present an interesting case of a 69-year-old female with a past medical history of chronic atrial fibrillation treated with a DOAC (apixaban) who was diagnosed with AMI despite being compliant with her anticoagulant. Her anticoagulation was promptly reversed and she was taken for urgent surgical intervention yielding a good outcome. Later, due to the failure of anticoagulation on apixaban her anticoagulant was changed to warfarin to prevent the recurrence of thromboembolism and follow-up showed she was doing well.

Novel Anticoagulants and Hip Fractures in the Elderly.

Introduction Early surgery is recommended in hip fractures to reduce morbidity and mortality. Surgery is often delayed in patients on novel direct oral anticoagulants (DOACs). The purpose of our study was to investigate the impact of DOACs on patients with hip fractures. Methods A retrospective comparative analysis was performed. A total of 766 patients presented with neck of femur fractures in the study period. Patients under the age of 60, those managed conservatively and those on alternative anticoagulation (including warfarin, clopidogrel and aspirin) were excluded. Forty-seven (6.1%) patients were on DOACs, to which a group of 47 patients was matched for age, gender, fracture type and intervention to minimise confounding. Primary outcome data on time to surgery (TTS), pre-/postoperative haemoglobin, haemoglobin drop, length of stay (LOS) and 30-day mortality were collected, as well as secondary outcome data on blood transfusion and wound complications. The Charlson Comorbidity Index (CCI) was calculated for all patients. Results The mean Charlson Comorbidity Index was significantly increased in the DOAC group (p<0.0001). The mean time to surgery was 49.5 hours in the DOAC group versus 31.3 hours in the control group (p=0.0002). Haemoglobin drop for DOAC patients was 16.9 g/L and 15.9 g/L for control patients (p=0.6). Similarly, no significant increase in transfusion was required (p=0.74). Six DOAC patients and two control group patients died within 30 days of surgery (p=0.13). Wound complications were seen in five (10.6%) patients on DOAC and two (4.2%) patients in the control group (p=0.02). Conclusion The results demonstrate statistically significantly higher comorbidities, delay in surgery and higher wound complications in patients on DOAC but no significant difference in haemoglobin drop, blood transfusion and mortality.

Mortality Rate in Upper Gastrointestinal Bleeding Associated with Anti-Thrombotic Therapy Before and During Covid-19 Pandemic.

Introduction: During the last few years, a progressive higher proportion of patients have had upper gastrointestinal bleeding (UGIB) related to antithrombotic therapy. The introduction of direct oral anticoagulant (DOAC) and COVID-19 pandemic may change the incidence, mortality, and follow-up, especially in patients at high risk of bleeding. Patients and Methods: We studied the use of anti-thrombotic therapy (AT) in patients with upper gastrointestinal bleeding for 5 years (January 2017-December 2021) including Covid-19 pandemic period (March 2020-December 2021). We analyzed mortality rate, rebleeding rate and need for transfusion in patients with AT therapy compared with those without AT therapy and risk factors for mortality, and also the incidence of gastrointestinal bleeding in patients admitted for COVID-19 infection. Results: A total of 824 patients were admitted during Covid-19 pandemic period and 1631 before pandemic period; a total of 426 cases of bleeding were recorded in patients taking antithrombotic therapy and the frequency of antithrombotic therapy in patients with UGIB was higher in pandemic period (24.39% versus 13.8%). Unadjusted mortality was 12.21%, similar with patients with no antithrombotic treatment but age-adjusted mortality was 9.62% (28% lower). The rate of endoscopy was similar but fewer therapeutic procedures were required. Mean Hb level was 10% lower, and more than 60% of patients required blood transfusion. Conclusion: Mortality was similar compared with patients with no antithrombotic therapy, fewer therapeutic endoscopies were performed and similar rebleeding rate and emergency surgery were noted. Hb level was 10% lower and a higher proportion of patients required blood transfusions. Mortality was higher in DOAC treatment group compared with VKA patients but with no statistical significance. The rate of upper gastrointestinal bleeding in Covid-19 positive hospitalized cases was 0.58%. The mortality risk in multivariate analysis was associated with GB score, with no endoscopy performed, with obscure and variceal bleeding and with LMWH versus VKA therapy.

Hemorrhagic Pericardial Effusion From Apixaban Use: Case Report and Literature Review.

Direct oral anticoagulants (DOACs) have revolutionized therapy for stroke prophylaxis in patients with non-valvular atrial fibrillation. These medications are generally well tolerated and are not associated with the inconvenience of repeat international normalized ratio (INR) checks. While bleeding in general is a common side effect associated with DOACs, especially from a gastrointestinal source, spontaneous hemorrhagic pericardial effusions are not seen frequently. Herein, we present a case of a patient who developed a hemorrhagic pericardial effusion three days after the initiation of apixaban. We also summarize the current data that is available showing this side effect and highlight an important risk factor that may predispose patients to this complication.

Safety and Efficacy of Apixaban vs Warfarin in Patients With Stage 4 and 5 Chronic Kidney Disease: A Systematic Review.

Warfarin has been an anticoagulant of choice in patients with advanced Chronic Kidney Diseases (CKD) at stages 4 and 5 for decades, but with the advent of Novel Oral Anticoagulants (NOACs), there has been a sharp rise in their prescriptions. Among all NOACS, apixaban is the least reliant on kidney function and is a very popular choice for this patient population. However, being utilized extensively, most of the landmark trials evaluating the safety and efficacy of apixaban excluded patients with Creatinine Clearance (CrCl) <25mL/min/1.73 m2 or Serum Creatinine (SCr) ≥2.5mg/dL. Its approval for advanced CKD patients came from limited pharmacokinetic data only. We conducted a systematic review comparing the safety and efficacy of apixaban to warfarin in patients with stage 4 and 5 CKD and on dialysis. We queried major research literature databases, including MEDLINE, PubMed, PubMed Central (PMC), Cochrane Central, and ScienceDirect to find relevant articles without any time or language restrictions. After screening and quality checks, we identified 11 studies relevant to our research question, of which nine were retrospective cohort studies, one was a post-hoc analysis of a randomized controlled trial (RCT), and one was an RCT. The included studies had a total of 27,007 patients, with 4,335 patients taking apixaban and 22,672 on warfarin. The results indicate that the overall efficacy of apixaban was equivalent to warfarin for the prevention of stroke, systemic embolization, and recurrent venous thromboembolism, but apixaban showed an equivalent and, in some studies, better safety profile than warfarin concerning the occurrence of bleeding. Apixaban may hence be considered a reasonable alternative to warfarin in patients with Stage 4 or 5 CKD and receiving dialysis. In light of the reviewed articles, we conclude that apixaban has similar efficacy and somewhat superior safety profile to warfarin, with more randomized controlled trials required to add to the evidence.

Systematic Review and Meta-Analysis: Can We Compare Direct Oral Anticoagulants to Warfarin in Patients With Atrial Fibrillation and Bio-Prosthetic Valves?

Background There are no clear consensus guidelines on the indications and types of anticoagulation therapies in patients with bio-prosthetic valves either with concomitant atrial fibrillation (AF) or sinus rhythm. In our meta-analysis, we assessed the safety and efficacy of DOACs as compared to the standard treatment with warfarin in patients with AF and bioprosthetic valves. Methods We included randomized controlled trials (RCTs), cohort studies in the English language, and studies reporting patients with valvular heart disease that included bioprosthetic valvular disease. A systematic literature review using Embase, PubMed, and Web of Science was performed using the terms "Direct Acting Oral Anticoagulant," "Oral Anticoagulants," "Non-Vitamin K Antagonist Oral Anticoagulant," "Atrial Fibrillation," "Bioprosthetic Valve" for literature published prior to January 2021. Extraction of data from included studies was carried out independently by three reviewers from Covidence. We assessed the methodical rigor of the included studies using the modified Downs and Black checklist. Results Four RCTs and one observational study (n=1776) were included in our study. A random-effect model using RevMan (version 5.4; The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen) was used for data analysis. The pooled data showed that there was a non-significant reduction in the incidence of stroke and systemic embolism in the patients taking DOACs as compared to warfarin (HR 0.69; 95% CI, 0.29, 1.67; I2 = 50%). The incidence of major bleeding was lower in the DOACs group; the difference was statistically significant (HR 0.42; 95% CI, 0.26, 0.67; I2 = 7%). The difference was not statistically significant for all-cause mortality in both groups (HR 1.24; 95% CI, 0.91, 1.67; I2 = 0%). Conclusion Our results showed that there was no difference in the outcomes of stroke and systemic embolism between DOACs and warfarin but there were statistically significantly lower major bleeding events. We conclude that larger clinical trials are needed to assess the true safety and efficacy of DOACs in patients with AF and bioprosthetic valves.

Anticoagulation After Ischemic Stroke or Transient Ischemic Attack (TIA) in the Time of Direct Oral Anticoagulation (DOAC) and Thrombectomy.

Objective To assess anticoagulation (AC) timing and appropriateness in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) due to atrial fibrillation (AF) in a predominantly Hispanic community hospital in the era of direct oral AC (DOAC) and endovascular thrombectomy (EVT). Methods Adult patients presenting with known or new-onset AF and primary diagnosis of AIS/TIA admitted to Baptist Hospital of Miami between January 2018 and January 2019 were included. AC appropriateness was determined on medical history and concordance with American Heart Association AHA/American Stroke Association (ASA) AC guidelines. Median time from AIS/TIA diagnosis to AC initiation was the primary endpoint. AC guideline concordance on admission and at discharge, discordant justification, and AC selection were secondary endpoints. Results The sample included 120 patients. AC initiation was five days (interquartile range (IQR) 2-9) following AIS/TIA. Patients' receiving intravenous (IV) alteplase experienced a 1.4-day delay in AC initiation (x̅=5.44, SE=1.05, p<.05). There was no significant delay for those receiving EVT. A symptomatic hemorrhagic transformation occurred in 3% (n=3) of patients; only one patient was initiated on AC prior to the event. No recurrent AIS/TIAs occurred prior to discharge. Guideline-based AC concordance increased by 14% to 96% from admission to discharge. Apixaban (78%, n=52) was the most prescribed anticoagulant during hospitalization. Discussion This study suggests that early AC initiation for patients with AF and AIS/TIA with or without IV alteplase and/or EVT is a safe and effective stroke prevention intervention. Further, it identified a need for improved concordance with guideline-based AC within the clinic setting.

An Observational Study to Evaluate the Effectiveness of Rivaroxaban in the Management of Cerebral Venous Sinus Thrombosis.

Background and objectives Cerebral venous sinus thrombosis (CVST) is a relatively rare and underdiagnosed type of stroke. Rivaroxaban is licensed for venous thromboembolism in patients opting for elective knee and hip replacement surgeries, preventing pulmonary embolism and precluding stroke and systemic embolism in sufferers of non-valvular atrial fibrillation. Beneficial outcomes depicting the efficacious role of rivaroxaban in treating CVST are under study. Materials and methods We performed a prospective observational study in patients diagnosed with CVST in the medicine or neurology unit of a tertiary care hospital in Karachi, Pakistan, between January 2019 and December 2019. The diagnosis of CVST was made by magnetic resonance venography (MRV) in all the cases. Follow-up visits were scheduled at three months and six months, and the occurrence of thrombotic events or bleeding complications was recorded. Follow-up was done by magnetic resonance imaging at three and six months to assess vessel recanalization. Excellent outcome was defined as a modified Rankin Scale (mRS) of 0 or 1. A total of 31 patients were meeting the inclusion criteria and were inducted into the study after informed consent. Results The mean age of the study population was 35.11 ± 8.96 years with 71% females and 29% males. The most prevalent etiology was the pregnancy/postpartum period (52%) followed by antiphospholipid syndrome (23%). The frequent clinical manifestations were headache (84%) followed by vomiting (38%), altered level of consciousness (35%), focal deficit/limb weakness (32%), aphasia (29%), blurring of vision (26%), and seizures (23%). Radiological studies showed that the vessels chiefly occluded in our study were superior sagittal sinus (29%), transverse sinus (23%), sigmoid sinus (16%), jugular vein (9%), and cortical veins (3%). Common features on magnetic resonance imaging (MRI) were cerebral edema (45%), hemorrhage (39%), infarct incidence (32%), and raised intracranial pressure (26%). Clinical outcomes showed 55% of patients had partial recanalization and 39% had complete recanalization after a period of six months of the administration of rivaroxaban. Ninety-three percent (93%) of sufferers recovered excellently according to mRS and only 3% developed recurrent CVST within a span of six months. The frequency of thrombotic events and bleeding complications were reported in 6% of patients, respectively, while mortality reported was also 6%. Conclusion Rivaroxaban has shown promising results in the management of our CVST patients, hence, it further warrants randomized controlled trials of rivaroxaban against conventional treatments to prove its significant role.

The Use of Rivaroxaban for Unprovoked Pulmonary Embolism in the Setting of Antithrombin Deficiency.

A 24-year-old woman with antithrombin (AT) deficiency presented with right-sided pleuritic chest pain of five days duration with diagnosis of pulmonary embolism (PE) made at an outside hospital. After discussion of treatment options with the patient, her treatment was changed to rivaroxaban protocol. The case illustrates an appropriate treatment plan for patients with AT deficiency presenting with unprovoked PE, especially when prioritizing ease of use.

The Use of Direct Oral Anticoagulants in the Management of Venous Thromboembolism in Patients With Obesity.

Introduction The use of direct oral anticoagulants (DOACs) has gained significant traction given the lack of therapeutic monitoring and the need for anticoagulant bridging. There is a paucity of data on their effectiveness in obese patients with venous thromboembolism (VTE). Preliminary subgroup and pharmacokinetic analyses suggest reduced efficacy in those with a bodyweight >120 kg or body mass index (BMI) ≥40 kg per m2 and it is currently not recommended that these agents be used as first-line agents. We aimed to assess the rate of VTE recurrence in obese patients diagnosed with VTE and treated with DOAC therapy. Methods We utilized the Health Facts Center National Data Warehouse (Cerner) to perform a retrospective analysis of patients with VTE (acute deep venous thrombosis (DVT) or pulmonary embolism) that presented to the hospital between 2010 and 2016 and were managed with DOACs. The cohort of patients diagnosed with DVT or PE were identified using International Classification of Disease (ICD-9-CM, ICD-10-CM). Patients were divided into two groups based on their weight: 1) weight <120 kg or 2) weight>120 kg. Six-month VTE recurrence rates were recorded. Summary and univariate statistics were performed. Results A total of 18,147 patients with a mean (±SD) age of 62 (17) years were included; 48% (n=8732) were male. A total of 2,419 (13%) patients weighed >120 kg while the rest (N=15,728, 87%) weighed <120 kg. There were significantly more female patients weighing<120 kg (54% vs 42%, p<0.0001); otherwise, there was no significant difference in age or tobacco use between both groups (p>0.05). There was no significant difference in six-month readmission rates for VTE recurrence in patients that weighed <120 kg (34%) in comparison with patients >120 kg (36%) (p=0.08). Conclusion Our study suggests that the use of DOACs in obese patients is equally efficacious with similar VTE recurrence rates in comparison with non-obese patients. This study paves the way for prospective multi-institutional randomized control trials to further reinforce the safe use of such agents in this patient population.

Perioperative Management in Patients With Undergoing Direct Oral Anticoagulant Therapy in Oral Surgery - A Multicentric Questionnaire Survey.

AIM: The purpose of this study was to survey the current opinions of hospitals and medical practices concerning the perioperative management of patients undergoing direct oral anticoagulant therapy (DOAC) and discuss recommendations for the clinical practice. MATERIALS AND METHODS: A questionnaire with 13 topics and multiple ordinal-polytomous subitems was designed and sent to 120 Departments of Oral and Maxillofacial Surgery in Austria, Switzerland and Germany, as well as to 85 oral and maxillofacial/oral surgeons in medical offices in Hamburg, Germany. The data were statistically evaluated by Chi-square, Fisher's exact and Jonckheere-Terpstra tests. RESULTS: The rate of response was 42%. Thirty-seven percent of respondents reported treating over 50 patients per year with undergoing DOAC therapy and only 18% assess a high bleeding risk [33% for vitamin K antagonists (VKA)]. In contrast to that, 62% of respondents would interrupt the DOAC therapy for extraction of one tooth, while 94% would continue VKA therapy. Significantly more clinicians apply suture than those in a medical office. The use of additional hemostatic measures varied between clinic and medical practice. There was a clear request for more detailed guidelines. CONCLUSION: The study shows the current opinion for perioperative management of patients undergoing DOAC therapy. Multi-centric studies under controlled conditions are needed for a safer treatment of anticoagulated patients as therapy strategies differ greatly between institutions and therefore a complication analysis is hardly possible.