Standardized DOAC interruption protocol resulted in 7.6% of patients having preoperative DOAC levels ≥30 ng/mL, with 2.9% in high bleeding risk and 28.9% in moderate bleeding risk surgeries.
Cohort (n=257)
Yes
Does a standardized DOAC interruption protocol result in preoperative DOAC levels <30 ng/mL in adult patients undergoing elective surgery?
A standardized DOAC interruption protocol before elective surgery successfully achieves preoperative DOAC levels <30 ng/mL in most patients, and elevated levels were not associated with increased surgical blood loss.
Effect estimate: 7.6% (95% CI, 4.9%-11.6%) (95% CI 4.9%-11.6%)
Importance Before elective surgery, direct oral anticoagulants (DOACs) are discontinued following a standardized protocol. However, this could result in insufficient lowering of DOAC levels that could increase bleeding risk. Objective To estimate the proportion of patients with elevated DOAC levels at the time of elective surgery, evaluate factors associated with DOAC levels, and examine associated blood loss. Design, Setting, and Participants This cohort study (DOAC Level Prior to Incision DALI) assessed adult patients prescribed a DOAC (apixaban, dabigatran, or rivaroxaban) for any indication and at any dose, undergoing an elective procedure requiring DOAC interruption between May 27, 2018, and February 25, 2024, at 2 Dutch hospitals. Exposure Standardized interruption protocol (1 day before moderate- and 2 days before high bleeding-risk procedures) with interruption adjustments for the patient’s kidney function. Main Outcomes and Measures Blood was drawn immediately before surgery to determine DOAC levels (by liquid chromatography–mass spectrometry). Proportions of preoperative DOAC levels of 30 ng/mL or higher and their 95% CIs were estimated, stratified by DOAC type and surgical bleeding risk. Factors associated with DOAC levels were identified through multivariable linear regression. Surgical blood loss and 30-day postoperative complications were described according to DOAC concentrations. Results The study was terminated after including 257 patients (100 receiving apixaban, 100 receiving rivaroxaban, and 57 receiving dabigatran due to the slow inclusion rate of those receiving dabigatran; median IQR age, 72 66-78 years; 173 male 67%); 212 patients (82%) underwent a high bleeding-risk operation. Preprocedural DOAC levels were 30 ng/mL or higher in 7.6% (95% CI, 4.9%-11.6%) of patients. Dabigatran and rivaroxaban had similar proportions, whereas 13.1% (95% CI, 7.8%-21.2%) of patients treated with apixaban had levels of 30 ng/mL or higher. Treatment with apixaban, decreased kidney function, and a shorter interruption time were associated with higher levels. Surgical blood loss (median range, 0 0-4250 mL) was not associated with DOAC levels. Twelve patients (4.7%; 95% CI, 2.7%-8.0%), who all had DOAC levels less than 30 ng/mL, experienced major bleeding. Conclusions and Relevance In this cohort study, most patients following the current protocol had DOAC levels less than 30 ng/mL, although the proportion of patients with elevated levels was higher for apixaban. Preoperative DOAC levels were not associated with blood loss during surgery.
Camilleri et al. (Wed,) conducted a cohort in Adult patients receiving direct oral anticoagulants (apixaban, rivaroxaban, or dabigatran) undergoing elective procedures requiring DOAC interruption according to a standardized protocol with kidney function adjustment (n=257). Standardized DOAC interruption protocol was evaluated on Proportion of patients with preoperative DOAC levels ≥30 ng/mL measured by liquid chromatography–mass spectrometry immediately before surgery (7.6% (95% CI, 4.9%-11.6%), 95% CI 4.9%-11.6%). Standardized DOAC interruption protocol resulted in 7.6% of patients having preoperative DOAC levels ≥30 ng/mL, with 2.9% in high bleeding risk and 28.9% in moderate bleeding risk surgeries.