THE STANDARDISED PERIXa protocol for perioperative factor Xa inhibitor discontinuation appears to be a safe and reasonable strategy for patients with atrial fibrillation (AF) undergoing procedures with minimal to low bleeding risk, with postprocedural rates of major bleeding at 0.1% and thromboembolism at 0%.
The discontinuation of anticoagulation therapy before medical procedures is a common concern in clinical practice, particularly for patients with AF receiving factor Xa inhibitors. The risk of bleeding often leads to interruptions in treatment, even for procedures with minimal to low bleeding risk, such as endoscopies, dental procedures, and ocular surgeries. The PERIXa protocol provides a standardized approach to managing perioperative anticoagulation, aiming to minimize both bleeding and thromboembolic complications while ensuring patient safety.
This prospective, multicentre, single-arm cohort study conducted in Korea included 1902 patients with AF who were receiving factor Xa inhibitors and scheduled for procedures with minimal to low bleeding risk. Patients followed the PERIXa protocol, which involved discontinuing their last dose of factor Xa inhibitor (apixaban, edoxaban, or rivaroxaban) 24 hours before the procedure and resuming treatment the following day. The primary outcome was major bleeding within 30 days post-procedure, while secondary outcomes included thromboembolic events. The modified intention-to-treat analysis showed a major bleeding rate of 0.1% (2 out of 1902 patients) and no thromboembolic events. The findings remained consistent across procedure categories and anticoagulant types.
The results of this study support the safety and practicality of the PERIXa protocol in perioperative management for patients with AF undergoing low-risk procedures. The extremely low rates of major bleeding and absence of thromboembolic events suggest that strict adherence to this standardized strategy can help balance bleeding and clotting risks effectively. Clinicians can consider implementing this protocol to optimise patient care, reducing unnecessary anticoagulation interruptions while maintaining procedural safety. Future research should explore the application of PERIXa in broader populations and higher-risk procedures to refine perioperative anticoagulation strategies further.
Katrina Thornber, EMJ
Reference
Lee S et al. Perioperative factor Xa inhibitor discontinuation for patients undergoing procedures with minimal or low bleeding risk. JAMA Netw Open. 2025;8(2):e2458742.
