Key result
Standardized DOAC interruption yields low preoperative drug levels with zero 30-day major bleeding in orthopedic surgery.
Why the study?
Although guidelines recommend standardized preoperative DOAC interruption protocols, actual preoperative plasma levels and their clinical implications in real-world surgical populations are not well characterized.
Does a standardized preoperative DOAC interruption protocol result in low preoperative plasma concentrations and low rates of postoperative bleeding and thromboembolic events in adults undergoing high-bleeding-risk elective orthopedic surgery?
Cohort (n=54)
No
Does a standardized preoperative DOAC interruption protocol result in low preoperative plasma concentrations and low rates of postoperative bleeding and thromboembolic events in adults undergoing high-bleeding-risk elective orthopedic surgery?
Standardized preoperative DOAC interruption protocols reliably achieve low or undetectable plasma drug levels and prevent major bleeding or thromboembolic events in patients undergoing high-risk elective orthopedic surgery, indicating routine preoperative level testing is unnecessary.
Answers are grounded in this paper and cite their sources.
Supports guideline-directed DOAC interruption without routine testing in elective orthopedic surgery; extends observational data but leaves confirmation to larger trials.
Objective: Treatment with direct oral anticoagulants is usually interrupted prior to surgery to reduce bleeding risk. Current guidelines recommend standardized interruption protocols, but the actual preoperative plasma levels and their clinical implications in real-world surgical populations are not well characterized. The aim of this study was to assess preoperative DOAC plasma concentrations and postoperative bleeding and thromboembolic outcomes in patients undergoing elective orthopedic surgery. Methods: We conducted a prospective observational study at Danderyd Hospital, Stockholm, Sweden. Adults (≥ 18 years) treated with apixaban, rivaroxaban, or dabigatran for atrial fibrillation or venous thromboembolism and scheduled for high-bleeding-risk orthopedic procedures were included. DOAC interruption followed national guidelines. Plasma DOAC levels were measured preoperatively using LC-MS/MS. Clinical outcomes, including bleeding and thromboembolic events, were recorded up to 30 days postoperatively. Results: A total of 54 patients receiving ongoing DOAC therapy (mean age, 75.5 years; 54% male) were included, of whom 87% were on apixaban. Plasma DOAC concentrations had a mean of 6.7 ng/mL (range, <1.9 to 23.1 ng/mL), and 38% of patients had levels below the limit of detection (< 2.0 ng/mL). One patient had a concentration >30 ng/mL. Five patients (16%) experienced clinically relevant non-major bleeding; four of these had undetectable DOAC levels. No major bleeding, thromboembolic events, or deaths were observed. Conclusions: Standardized interruption protocols for DOAC therapy result in low or undetectable plasma levels in most patients undergoing high-risk elective orthopedic surgery. Routine preoperative DOAC level testing appears unnecessary in the general population but may be valuable in subgroups at high risk of bleeding.
No takes yet. Share an insight, caveat, or question.
Axenhus et al. (2026) conducted a cohort in Atrial fibrillation or venous thromboembolism undergoing elective high-bleeding-risk orthopedic surgery (n=54). Standardized preoperative DOAC interruption (apixaban, rivaroxaban, or dabigatran) was evaluated on Preoperative DOAC plasma concentrations and 30-day postoperative clinically relevant non-major bleeding, major bleeding, and thromboembolic events. Standardized DOAC interruption before orthopedic surgery yielded mean plasma levels of 6.7 ng/mL (38% <2.0 ng/mL), with 16% non-major bleeding and 0% major bleeding or thromboembolism at 30 days.
Synapse has enriched 10 related papers. Consider them for comparative context: