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Over the last decade, the availability of non-vitamin K antagonist oral anticoagulants (NOACs) has significantly changed the daily clinical practice in managing thromboembolic risk in patients with atrial fibrillation (AF).1 Guidelines for AF management have established that NOACs are the preferred treatment for the majority of AF patients;2 however, recent data from ‘real-life’ registries clearly show that a significant proportion of patients are still treated with vitamin K antagonists.3–8 Nevertheless, the role of NOACs still seems to be debated in some specific circumstances, such as their role in the peri-operativemanagementof patientswithAF, in relation to interruption or continuation of anticoagulation. Themanagement of oral anticoagulation (OAC) therapy in the peri-operative setting has been long debated. Despite the absence of solid evidence, bridging OAC therapywith unfractioned heparin or low molecular weight heparin (LMWH) was commonly suggested.9,10 In 2015, the ‘Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery’ (BRIDGE) trial provided an answer to this important issue regarding warfarin,11 demonstrating that while patients undergoing bridging therapy with LMWH had a similar risk for thromboembolic complications, they were at significantly increased risk of major bleeding.11 Although there has been some clarification about peri-procedural management with warfarin, uncertainty still remains about peri-procedural NOAC management, due to the lack of solid data and limited clinical experience. In the previous issue of Thrombosis and Haemostasis, Douketis and colleagues presented a sub-group analysis on peri-operative management and outcomes in AF patients treated with warfarin or edoxaban, derived from the “Effective Anticoagulationwith Factor Xa Next Generation in Atrial Fibrillation–Thrombolysis in Myocardial Infarction 48” trial.12 Of the 21,105 patients originally enrolled in the trial, 7,193 (34.1%) required surgery or an invasive procedure, and were equally randomized to warfarin, edoxaban high dose (60 or 30 mg) and edoxaban low dose (30 or 15 mg), with no major differences across the three groups. Themost common procedures were cardiac, gastrointestinal endoscopy, dental and electrophysiological. Among those undergoing elective procedures, 3,116 (43.3%) had their anticoagulation interrupted, defined as warfarin/edoxaban stopped for 4 to 10 days before the procedure, while 4,077 (56.7%) were defined as ‘anticoagulant continued’, having stopped randomized treatment 3 days (or not stopped at all) before the procedure.12 A 30-day observation periodwas established to determine if there were differences in efficacy and safety betweenwarfarin and the two doses of edoxaban in patients undergoing elective procedures, in patients with interrupted or continued anticoagulation treatment. In the anticoagulant interrupted group, rates of stroke or systemic embolism at 30 days were 0.6, 0.5 and 0.9% for the warfarin, edoxaban high dose and edoxaban low dose groups, respectively (p 1⁄4 0.53 for differences across the groups). Corresponding figures in the anticoagulation-continued group were 1.1, 0.7 and 0.9%, with no significant between-group differences. Regarding the main safety outcome, major or clinically relevant non-major (CRNM) bleeding was reported in 3.9, 4.2 and 3.6% of patients receiving warfarin, edoxaban high dose and edoxaban low dose, respectively, for the anticoagulation interrupted group, with no significant differences across the three treatment groups. Among patients who continued anticoagulation, rates of major/CRNM bleeding in

Use of NOACs in the Peri-Operative Management of Patients with Atrial Fibrillation: To Stop, Bridge or Continue?