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3-Day Interruption of

Direct Oral Anticoagulants

Appropriate for

Most Procedures

European Heart Journal

Take-home message

This prospective study (N = 422) evaluated the predictors of direct oral anticoagulant

concentrations and strategies to minimize bleeding prior to invasive procedures.

The results revealed that renal function, duration of discontinuation prior to the

procedure, antiarrhythmic treatment, and high-risk bleeding procedures were

associated with higher periprocedural bleeding events. The direct oral anticoagu-

lant (DOAC) assay was more effective in predicting bleeding events than standard

hemostasis assays.

The authors concluded that a 3-day preprocedure discontinuation of DOACs will

minimize the anticoagulant effect for most patients; however, patients with renal

impairment or those receiving antiarrhythmic treatment will require a longer duration

of discontinuation.

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 multicen-

tre study included 422 DOAC-treated patients

requiring an invasive procedure. Pre-proce-

dural DOAC concentration ([DOAC]) and routine

haemostasis assays were performed to deter-

mine i/the proportion of patients who achieved

a minimal pre-procedural [DOAC] (≤30ng/mL)

according to the duration of DOAC discontin-

uation, ii/the predictors of minimal [DOAC] and,

iii/the ability of routine assays to predict mini-

mal [DOAC]. Lastly, we assessed the predictors

of peri-procedural bleeding events. The dura-

tion of DOAC discontinuation ranged from 1 to

218 h and pre-procedural [DOAC] from≤30 to

527ng/mL. After a 49–72-h discontinuation, 95%

of the [DOAC] were≤30ng/mL. A 72-h discontin-

uation predicted concentrations≤30ng/mL with

91% specificity. In multivariable analysis, duration

of DOAC discontinuation, creatinine clearance

<50mL/min and antiarrhythmics were independ-

ent predictors of minimal pre-procedural [DOAC]

(concordance statistic 0.869; 95% confidence

interval: 0.829–0.912). Conversely, routine hae-

mostasis assays were poor predictors. Last,

creatinine clearance <50mL/min, antiplatelets

and high-bleeding risk procedures were pre-

dictors of bleeding events.

CONCLUSION

A last DOAC intake 3 days before

a procedure resulted in minimal pre-proce-

dural anticoagulant effect for almost all patients.

Moderate renal impairment, especially in dab-

igatran-treated patients, and antiarrhythmics in

anti-Xa-treated patients should result in a longer

DOAC interruption. In situations requiring test-

ing, routine assays should not replace DOAC

concentration measurement.

Predictors of pre-procedural concentrations of

direct oral anticoagulants: a prospective mul-

ticentre study.

Eur Heart J

2017 Jul 24;[EPub

Ahead of Print], A Godier, A-S Dincq, A-C Mar-

tin, et al.

www.practiceupdate.com/c/56375

COMMENT

By Amish N Raval

MD

T

he direct oral anticoagulants

(DOACs) have emerged as alterna-

tives to warfarin for the prevention

and treatment of thromboembolic dis-

ease. DOACs are appealing because they

have a more predictable pharmacoki-

netic profile and have fewer food–drug

and drug–drug interactions than warfa-

rin. Despite their widespread use, most

clinicians remain apprehensive about

managing DOACs in the periprocedural

setting. In the United States, the absence

of FDA-approved assays to directly meas-

ure DOAC concentration and antidotes for

the factor Xa inhibitors have contributed

to these concerns.

Godier et al sheds light on this issue by

demonstrating that DOAC concentration

predictably drops to almost undetectable

(<30 ng/dL) levels after 72 hours of cessa-

tion in a prospective real-world registry of

patients who are on DOACs and require

an assortment of elective procedures.

This observation will undoubtedly assist

investigators in designing future DOAC

interruption protocols. Managing DOACs

in the periprocedural setting requires an

understanding of a patient’s thromboem-

bolic risk and bleeding risk. Contributing

to these two risks include variables such

as age, gender, frailty, renal function,

coexisting antithrombotic medications,

bleeding risk associated with the proce-

dure being planned, and postoperative

sequelae such as prolonged bedrest or

re-operations. Until we have more pro-

spectively acquired data such as that

provided by Godier et al, healthcare sys-

tems are strongly encouraged to develop

periprocedural DOAC interruption proto-

cols with multidisciplinary input.

Dr Raval is Associate

Professor of Medicine,

Director: Cardiovascular

Clinical Research, University

of Wisconsin School of

Medicine and Public Health,

Madison, Wisconsin.

ARRHYTHMIAS/HEART RHYTHM DISORDERS

23

VOL. 2 • NO. 2 • 2017