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Stretton B, Kovoor J, Bacchi S, Booth A, Gluck S, Vanlint A, Afzal M, Ovenden C, Gupta A, Mahajan R, Edwards S, Brennan Y, Boey JP, Reddi B, Maddern G, Boyd M. Impact of perioperative direct oral anticoagulant assays: a multicenter cohort study. Hosp Pract (1995) 2023:1-8. [PMID: 37083232 DOI: 10.1080/21548331.2023.2206270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND There is little evidence to guide the perioperative management of patients on a direct oral anticoagulant(DOAC) in the absence of a last known dose. Quantitative serum titers may be ordered but there is little evidence supporting this. AIMS This multi-center retrospective cohort study of consecutive surgical in-patients with a DOAC assay, performed over a five-year period, aimed to characterize preoperative DOAC assay orders and their impact on perioperative outcomes. MATERIALS AND METHODS Patientsprescribed regular DOAC (both prophylactic and therapeutic dosing) with apreoperative DOAC assay were included. DOAC assay titer was evaluated againstendpoints. Further, patients with an assay were compared against anticoagulatedpatients who did not receive a preoperative DOAC assay. The primary endpointwas major bleeding. Secondary endpoints included perioperative hemoglobinchange, blood transfusions, idarucizumab or prothrombin complex concentrateadministration, postoperative thrombosis, in-hospital mortality andreoperation. Adjusted and unadjusted linear regression models were used forcontinuous data. Binary logistic models were performed for dichotomous outcomes. RESULTS 1065 patientswere included, 232 had preoperative assays. Assays were ordered most commonlyby Spinal (11.9%), Orthopedics (15.4%) and Neurosurgery (19.4%). For every10ng/ml increase in titer, the hemoglobin decreases by 0.5066g/L and the oddsof a preoperative reversal increases by 13%. Compared to those without anassay, patients with preoperative DOAC assays had odds 1.44x higher for majorbleeding, 2.98x higher for in-hospital mortality and 16.3x higher for receivinganticoagulant reversal. CONCLUSION A preoperativeDOAC assay order was associated with worse outcomes despite increased reversaladministration. However, the DOAC assay titer can reflect the patient'slikelihood of bleeding.
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Affiliation(s)
- Brandon Stretton
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide Adelaide, South Australia, Australia
- Central Adelaide Local Health Network, Adelaide, South Australia
| | - Joshua Kovoor
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide Adelaide, South Australia, Australia
- Central Adelaide Local Health Network, Adelaide, South Australia
| | - Stephen Bacchi
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Central Adelaide Local Health Network, Adelaide, South Australia
- Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia
| | - Andrew Booth
- Central Adelaide Local Health Network, Adelaide, South Australia
| | - Sam Gluck
- Northern Adelaide Local Health Network, Adelaide, South Australia
| | - Andrew Vanlint
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
| | - Mohammed Afzal
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
| | - Christopher Ovenden
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Central Adelaide Local Health Network, Adelaide, South Australia
| | - Aashray Gupta
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Rajiv Mahajan
- Central Adelaide Local Health Network, Adelaide, South Australia
- Northern Adelaide Local Health Network, Adelaide, South Australia
| | - Suzanne Edwards
- Adelaide Health Technology Assessment, The University of Adelaide, Adelaide, South Australia, Australia
| | - Yvonne Brennan
- Central Adelaide Local Health Network, Adelaide, South Australia
- Northern Adelaide Local Health Network, Adelaide, South Australia
| | - Jir Ping Boey
- Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia
| | - Benjamin Reddi
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
| | - Guy Maddern
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide Adelaide, South Australia, Australia
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Mark Boyd
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Northern Adelaide Local Health Network, Adelaide, South Australia
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Budd AN, Wood B, Zheng W, Rong LQ. Perioperative Management of Direct Oral Anticoagulants in Cardiac Surgery: Practice Recommendations Based on Current Evidence. J Cardiothorac Vasc Anesth 2022; 36:4141-4149. [PMID: 35965231 DOI: 10.1053/j.jvca.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/05/2022] [Accepted: 07/14/2022] [Indexed: 11/11/2022]
Abstract
An increasing number of patients on systemic oral anticoagulants present for cardiac surgery, and cardiac anesthesiologists should be well-informed on their management in the perioperative period. Direct oral anticoagulants (DOACs), including factor Xa inhibitors and direct thrombin inhibitors, are an attractive alternative to warfarin due to fewer dietary and drug interactions, less frequent monitoring requirements, and an improved patient adherence. Since the approval of DOACs by the Food and Drug Administration in 2010, the number of patients on these medications only has increased. The guidelines vary on the periprocedural management of DOACs for cardiac surgery. This review evaluated the current evidence for medication cessation before surgery, based on timing as well as plasma drug concentration. The practice recommendations of various monitoring tests and new evolving point-of-care testing are examined herein. The different reversal agents were discussed by the authors for both elective and urgent procedures. The cardiac anesthesiologist needs to be intimately familiar with the management and current best practices of DOACs for safe and appropriate patient care.
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Affiliation(s)
- Ashley N Budd
- Department of Anesthesiology, Northwestern Feinberg School of Medicine, Chicago, IL.
| | - Brendan Wood
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY
| | - William Zheng
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY
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Manji RA, Arora RC. Commentary: Should patients awaiting cardiac surgery who need anticoagulation be on direct oral anticoagulants or vitamin K antagonists? J Thorac Cardiovasc Surg 2020; 161:1876-1877. [PMID: 32057457 DOI: 10.1016/j.jtcvs.2019.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 12/24/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Rizwan A Manji
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada.
| | - Rakesh C Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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