The Direct Oral Anticoagulation Versus Vitamin K Antagonist After Cardiac Surgery Trial
- Conditions
- Bleeding Post Cardiac SurgeryIndication for Anticoagulation
- Interventions
- Drug: DOAC
- Registration Number
- NCT04284839
- Lead Sponsor
- Population Health Research Institute
- Brief Summary
The DANCE Trial is a multi-centre, randomized controlled trial comparing the safety of direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) in the early period (30 days) after cardiac surgery in patients with atrial fibrillation requiring oral anticoagulation.
- Detailed Description
Approximately 36,000 Canadian adults undergo cardiac surgery annually. Of these patients, about 10% have a prior history of atrial fibrillation (AF). In the early post-operative period after cardiac surgery, 30-60% of patients develop AF and, by the time of discharge, 32% of patients who underwent cardiac surgery have an indication for oral anticoagulation (OAC). AF is associated with a significantly higher risk of stroke, even when transient, and OAC is the standard for thromboembolic prevention in these patients. In the post-operative period, the balance of benefits and risks of OAC may differ and the safest and most effective OAC in that patient population is uncertain.
Vitamin K antagonists (VKAs), such as warfarin or coumadin, are the most used anticoagulants after cardiac surgery. In the Left Atrial Appendage Occlusion Study (LAAOS) III that recruited 4811 patients from 105 centres in 27 countries, 77% of patients with AF on OAC were discharged on a VKA after cardiac surgery. Among patients taking a DOAC preoperatively, 55% were switched to a VKA after surgery. Over the first post-operative year, most of those patients were gradually transitioned back to a DOAC. Although effective, the use of VKAs is limited by a narrow therapeutic index requiring frequent international normalized ratio (INR) measurements to ensure appropriate levels of anticoagulation. This key limitation leads to non-compliance and discontinuation. In addition, in the first 3 months after cardiac surgery, time in the therapeutic range is low, even with close monitoring by experienced prescribers.
In the last decade, DOACs - inhibitors of factor Xa or thrombin- have become broadly used in patients with AF. Treatment with a DOAC in patients with AF has been demonstrated to yield a lower risk of stroke or systemic embolism and a similar risk of major bleeding when compared to VKAs during long-term follow-up. Moreover, DOACs are more convenient for both patients and clinicians. They have a rapid onset of effect, fixed dosage that obviates the need for regular monitoring, and few interactions with food and other medications. In the postoperative setting, DOACs may also lead to shorter length of stay and reduced costs.
The purpose of this study is to establish whether DOACs are as safe as VKAs in the first few weeks after heart surgery. The results of this study will impact the treatment of hundreds of thousands of patients in the world every year.
A subset of 910 DANCE participants with a recent bioprosthetic aortic valve replacement will be enrolled in the SUNDANCE substudy (Subclinical valve thrombosis in patients with surgical bioprosthetic aortic valve replacement: An imaging substudy of the DANCE trial). SUNDANCE will examine the effects of DOACs versus VKAs on subclinical valve thrombosis and bioprosthetic valve function by conducting computed tomography (CT) scans and echocardiograms at 60 to 90 days after randomization.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 3500
- Age ≥18 years at the time of enrolment,
- Open heart surgery in the last 10 days,
- Atrial fibrillation requiring anticoagulation (including pre-existing or post-operative atrial fibrillation),
- Informed consent from either the patient or a substitute decision-maker.
- Mechanical valve replacement,
- Antiphospholipid syndrome (triple positive),
- Severe renal failure (Cockcroft-Gault equation; creatinine clearance <15 ml/min),
- Known significant liver disease (Child-Pugh classification B and C),
- Left ventricular thrombus,
- Ongoing bleeding, hemorrhagic disorders, or bleeding diathesis,
- Known contraindication for any DOAC or VKA,
- Women who are pregnant, breastfeeding, or of childbearing potential,
- Surgery including left ventricular assist device implantation or cardiac transplantation,
- Previously enrolled in this trial,
- Follow-up not possible,
- History of moderate or severe mitral valvular lesion (stenosis or regurgitation) that is not corrected during index cardiac surgery.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- FACTORIAL
- Arm && Interventions
Group Intervention Description Direct Oral Anticoagulation (DOAC) DOAC Patients in the intervention group will receive a DOAC at doses recommended for the indication, adjusted for their renal function is required. The choice of DOAC will be at the discretion of the treating physician. Vitamin K Antagonist VKA Patients in the control group will receive VKA once daily; the individual dose will be titrated to achieve a guideline-recommended INR range.
- Primary Outcome Measures
Name Time Method Major Bleeding 30-Days post-randomization Major bleeding at 30 days, defined as bleeding that results in death and/or symptomatic bleeding in a critical area or organ, bleeding into a surgical site requiring reoperation, bleeding leading to hospitalization (including presentation to an acute care facility without overnight stay) and/or bleeding that causes a drop in the hemoglobin level of 20g/L or more or that which requires the transfusion of ≥2 units of packed red blood cells or whole blood (as defined by the International Society of Thrombosis and Hemostasis)
- Secondary Outcome Measures
Name Time Method Composite of stroke and non-central nervous system systemic arterial embolism at 30 and 90 days. 30-Days and 90-Days post-randomization Major Bleeding 90-Days post-randomization Pleural or pericardial effusion requiring drainage 30-Days and 90-Days post-randomization Systemic arterial embolism 30-Days and 90-Days post-randomization Ischemic stroke 30-Days and 90-Days post-randomization Deep vein thrombosis 30-Days and 90-Days post-randomization Pulmonary Embolism 30-Days and 90-Days post-randomization Length of post-operative hospital stay 30-Days and 90-Days post-randomization All-Cause Mortality 6 Months post-randomization
Trial Locations
- Locations (16)
St Vincent's Hospital Melbourne
🇦🇺Fitzroy, Victoria, Australia
Royal Melbourne Hospital, University of Melbourne
🇦🇺Parkville, Victoria, Australia
University of Alberta Hospital
🇨🇦Edmonton, Alberta, Canada
St. Boniface Hospital
🇨🇦Winnipeg, Manitoba, Canada
Saint John Regional Hospital
🇨🇦Saint John, New Brunswick, Canada
Hamilton General Hospital
🇨🇦Hamilton, Ontario, Canada
Sunnybrook Hospital
🇨🇦Toronto, Ontario, Canada
Toronto General Hospital
🇨🇦Toronto, Ontario, Canada
Hôpital Sacré-Coeur de Montréal
🇨🇦Montreal, Quebec, Canada
Montreal Heart Institute
🇨🇦Montréal, Quebec, Canada
IUCPQ-ULaval
🇨🇦Quebec City, Quebec, Canada
Heart Center Leipzig
🇩🇪Leipzig, Saxony, Germany
University Hospital Jena
🇩🇪Jena, Thuringen, Germany
University Hospital Bonn Heart Center
🇩🇪Bonn, Germany
West-German Heart and Vascular Center, University of Duisburg-Essen
🇩🇪Essen, Germany
University Medical Center Hamburg-Eppendorf
🇩🇪Hamburg, Germany