Practice Update: Cardiology

ARRHYTHMIAS/HEART RHYTHM DISORDERS 23

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

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

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, 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,

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, 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.

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.

VOL. 2 • NO. 2 • 2017