A 49-72-hour discontinuation of DOACs resulted in minimal pre-procedural concentrations (≤30 ng/mL) in 95% of patients; duration, renal impairment, and antiarrhythmics were independent predictors.
Cohort (n=422)
Yes
What is the optimal duration of DOAC discontinuation to ensure minimal pre-procedural anticoagulant effect in patients undergoing invasive procedures?
Discontinuing DOACs 3 days before an invasive procedure ensures minimal pre-procedural anticoagulant effect for most patients, though longer interruption is needed for those with moderate renal impairment or on antiarrhythmics.
Effect estimate: concordance statistic 0.869 (95% CI 0.829-0.912)
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.
Godiér et al. (2017) conducted a cohort in DOAC-treated patients requiring an invasive procedure (n=422). DOAC discontinuation was evaluated on minimal pre-procedural [DOAC] (≤30 ng/mL) (concordance statistic 0.869, 95% CI 0.829-0.912). A 49-72-hour discontinuation of DOACs resulted in minimal pre-procedural concentrations (≤30 ng/mL) in 95% of patients; duration, renal impairment, and antiarrhythmics were independent predictors.