The proposed PAUSE-2 RCT study is the logical next step to the Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE) study, which was completed on August 31, 2018. Both studies address the perioperative management of patients with atrial fibrillation (AF) who are receiving a direct oral anticoagulant (DOAC) and require an elective surgery/procedure. PAUSE did not address safe management of patients having a high-bleed-risk surgery/neuraxial anesthesia in whom there is concern about bleeding, especially neuraxial-related epidural hematomas that can lead to paralysis; such patients are often managed by the approach recommended by the American Society of Regional Anesthesia (ASRA). In PAUSE-2, investigators will test the hypothesis: (i) for patients having a high-bleed-risk surgery/neuraxial anesthesia, the simpler "PAUSE management" is as safe (non-inferior) to the more complex "ASRA management". PAUSE-2 will establish a standard for perioperative DOAC management in patients having high-bleed-risk surgery or neuraxial anesthesia. To start, this will be a pilot study of a larger PAUSE-2-RCT. The investigators will be conducting this pilot study to assess the feasibility of the study at this smaller scale.
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Inclusion Criteria: * Adult (age ≥18 years) with AF/flutter who is receiving a DOAC: apixaban 2.5 mg or 5 mg BID; dabigatran 110 mg or 150 mg BID; or rivaroxaban 15 mg or 20 mg QD. * Undergoing an elective surgery/procedure associated with a high-bleed-risk or any surgery/procedure requiring neuraxial anesthesia (includes regional blocks) * Patient and their clinician are willing to adhere to DOAC interruption/continuation protocols. * Patient to resume DOAC after surgery/procedure (i.e., no intent to discontinue DOAC). Exclusion Criteria: * Creatinine clearance (CrCl) \<30 mL/min (dabigatran, rivaroxaban) and \<25 mL/min (apixaban) based on the Cockroft-Gault equation, which is recommended for DOAC dosing. * Patient taking a DOAC that is infrequently used (i.e., edoxaban, \<5% Canadian DOAC market share in 2018) or is not available for clinical use in Canada or Europe (i.e., betrixaban). * Patient taking a DOAC for a non-AF clinical indication (excluded to maintain study population homogeneity). * Cognitive impairment or psychiatric illness that precludes collection of follow-up data. * Inability or unwillingness to provide informed consent. * Previous participation in PAUSE-2.