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Eur Heart J. 2017 Aug 14;38(31):2431-2439. doi: 10.1093/eurheartj/ehx403.

Predictors of pre-procedural concentrations of direct oral anticoagulants: a prospective multicentre study.

Author information

1
Fondation Adolphe de Rothschild, Service d'Anesthésie-Réanimation, 25 rue Manin, 75019, Paris, France.
2
Inserm UMR-S1140, Faculté de Pharmacie, Université Paris Descartes, 4, avenue de l'Observatoire, 75006 Paris, France.
3
Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Department of Anesthesiology, Avenue du Docteur Gaston Thérasse, 1, 5530 Yvoir, Belgium.
4
Hôpital d'Instruction des Armées Percy, Service de Cardiologie, 101 Avenue Henri Barbusse, 92140 Clamart, France.
5
Hôpital Foch, Service d'Anesthésie, 40 Rue Worth, 92150 Suresnes, France.
6
Institut Mutualiste Montsouris, Service d'Anesthésie, 42 boulevard Jourdan, 75014 Paris, France.
7
AP-HP, Hôpital Cochin, Service d'Anesthésie-Réanimation, 27 rue du Faubourg-Saint-Jacques, 75014 Paris, France.
8
Hôpital Foch, Service de Biologie Clinique, 40 Rue Worth, 92150 Suresnes.
9
INSERM UMR-S1176, Université Paris-Sud, 80 rue du Général Leclerc, 94276 Le Kremlin-Bicêtre, France.
10
AP-HP, GH Pitié-Salpêtrière, Département de biostatistiques, 47-83 boulevard de l'Hôpital, 75013 Paris, France.
11
Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Hematology Laboratory, Avenue du Docteur Gaston Thérasse, 1, 5530 Yvoir, Belgium.
12
AP-HP, Hôpital Cochin, Laboratoire d'hématologie, 27 rue du Faubourg-Saint-Jacques, 75014 Paris, France.
13
Hôpital Pontchaillou, Laboratoire d'Hématologie, 2 Rue Henri le Guilloux, 35000 Rennes, France.

Abstract

Aims:

Patients receiving direct oral anticoagulants (DOACs) frequently undergo elective invasive procedures. Their management is challenging. We aimed to determine the optimal duration of DOAC discontinuation that ensures a minimal anticoagulant effect during the procedure.

Methods and results:

This prospective multicentre study included 422 DOAC-treated patients requiring an invasive procedure. Pre-procedural DOAC concentration ([DOAC]) and routine haemostasis assays were performed to determine i/the proportion of patients who achieved a minimal pre-procedural [DOAC] (≤30 ng/mL) according to the duration of DOAC discontinuation, ii/the predictors of minimal [DOAC] and, iii/the ability of routine assays to predict minimal [DOAC]. Lastly, we assessed the predictors of peri-procedural bleeding events. The duration of DOAC discontinuation ranged from 1 to 218 h and pre-procedural [DOAC] from ≤30 to 527 ng/mL. After a 49-72-h discontinuation, 95% of the [DOAC] were ≤30 ng/mL. A 72-h discontinuation predicted concentrations ≤30 ng/mL with 91% specificity. In multivariable analysis, duration of DOAC discontinuation, creatinine clearance <50 mL/min and antiarrhythmics were independent predictors of minimal pre-procedural [DOAC] (concordance statistic 0.869; 95% confidence interval: 0.829-0.912). Conversely, routine haemostasis assays were poor predictors. Last, creatinine clearance <50 mL/min, antiplatelets and high-bleeding risk procedures were predictors of bleeding events.

Conclusion:

A last DOAC intake 3 days before a procedure resulted in minimal pre-procedural anticoagulant effect for almost all patients. Moderate renal impairment, especially in dabigatran-treated patients, and antiarrhythmics in anti-Xa-treated patients should result in a longer DOAC interruption. In situations requiring testing, routine assays should not replace DOAC concentration measurement.

KEYWORDS:

Antiarrhythmic; Bleeding; Blood coagulation tests ; Direct oral anticoagulant; Invasive procedure; Renal

PMID:
28821169
DOI:
10.1093/eurheartj/ehx403
[Indexed for MEDLINE]

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