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Medline ® Abstract for Reference 45

of 'Perioperative management of patients receiving anticoagulants'

Predictors of pre-procedural concentrations of direct oral anticoagulants: a prospective multicentre study.
Godier A, Dincq AS, Martin AC, Radu A, Leblanc I, Antona M, Vasse M, Golmard JL, Mullier F, Gouin-Thibault I
Eur Heart J. 2017;38(31):2431.
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, creatinineclearance<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.
Fondation Adolphe de Rothschild, Service d'Anesthésie-Réanimation, 25 rue Manin, 75019, Paris, France.