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Douketis JD, Spyropoulos AC. Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA 2024; 332:825-834. [PMID: 39133476 DOI: 10.1001/jama.2024.12708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Importance Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism. Observations For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure. Conclusions and Relevance When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton, and McMaster University, Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York, New York
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Institute of Health System Science at the Feinstein Institutes for Medical Research, Manhasset, New York
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 286] [Impact Index Per Article: 286.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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3
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 95] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Buckley GT, Murphy B, Fleming N, Crowley MP, Harte JV. Removing direct oral factor Xa inhibitor interferences from routine and specialised coagulation assays using a raw activated charcoal product. Clin Chim Acta 2023; 550:117565. [PMID: 37769932 DOI: 10.1016/j.cca.2023.117565] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are increasingly prescribed for the prevention and treatment of thrombosis. However, DOACs are associated with extensive interference in coagulation assays. Herein, we evaluate raw activated charcoal (AC) as an adsorbent material, to minimise DOAC-associated interferences in routine and specialised coagulation parameters on CS-series analysers (Sysmex, Kobe, Japan). METHODS Commercial human-derived non-anticoagulated plasma materials, with or without increasing concentrations of anticoagulant, were assayed for routine and specialised coagulation parameters before and after treatment with AC. RESULTS Treatment of non-anticoagulated plasma with raw AC had minimal impact on routine and specialised coagulation parameters available on the CS-series; however, clinically relevant prolongations of certain activated partial thromboplastin time (APTT)-based assays were observed after treatment. Furthermore, in apixaban- and rivaroxaban-containing plasma material, AC efficiently adsorbed therapeutic and supratherapeutic DOAC concentrations; and, treatment with raw AC resolved DOAC-associated interferences on all affected routine and specialised coagulation parameters. CONCLUSIONS Overall, raw AC efficiently adsorbed apixaban and rivaroxaban from human-derived plasma, without significantly affecting the majority of underlying routine and specialised coagulation parameters available on CS-series analysers.
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Affiliation(s)
- Gavin T Buckley
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland; EOLAS Research Group, Cork University Hospital, Wilton, Cork, Ireland
| | - Ber Murphy
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
| | - Niamh Fleming
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
| | - Maeve P Crowley
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland; EOLAS Research Group, Cork University Hospital, Wilton, Cork, Ireland; Irish Network for Venous Thromboembolism Research (INViTE), Ireland
| | - James V Harte
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland; EOLAS Research Group, Cork University Hospital, Wilton, Cork, Ireland.
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Douketis JD, Spyropoulos AC. Perioperative Management of Anticoagulant and Antiplatelet Therapy. NEJM EVIDENCE 2023; 2:EVIDra2200322. [PMID: 38320132 DOI: 10.1056/evidra2200322] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Anticoagulant and Antiplatelet Drug ManagementManagement of patients on an anticoagulant or antiplatelet drug who require surgery or an invasive procedure is a common clinical problem. Douketis and Spyropoulos provide an evidence-based but practical approach to managing anticoagulants and antiplatelet drugs in the perioperative setting.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, New York
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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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Papageorgiou L, Hetjens S, Fareed J, Auge S, Tredler L, Harenberg J, Weiss C, Elalamy I, Gerotziafas GT. Comparison of the DOAC Dipstick Test on Urine Samples With Chromogenic Substrate Methods on Plasma Samples in Outpatients Treated With Direct Oral Anticoagulants. Clin Appl Thromb Hemost 2023; 29:10760296231179684. [PMID: 37278029 PMCID: PMC10272629 DOI: 10.1177/10760296231179684] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/02/2023] [Accepted: 05/17/2023] [Indexed: 06/07/2023] Open
Abstract
Identifying adherence to direct oral anticoagulants (DOACs) plays a major role in treatment efficacy and safety. The DOAC Dipstick can detect DOACs in urine samples of acutely diseased patients at plasma thresholds of about 30 ng/mL. A prospective observational consecutive cohort study was performed on outpatients taking DOACs. The presence of direct oral factor Xa inhibitors (DXIs) in patient urine samples were independently evaluated by visual interpretation of the DOAC Dipstick pad colors. DOAC plasma concentration was assessed using STA®-Liquid Anti-Xa and STA®-Liquid Anti-IIa chromogenic substrate assays. Positive DOAC Dipstick results were compared with a threshold plasma of DOAC concentration ≥30 ng/mL. Of 120 patients (age 55.4 + 16.1 years, female n = 63), 77 were on rivaroxaban and 43 on apixaban. Plasma concentrations were 129 ± 118 ng/mL for rivaroxaban, and 163 ± 130 ng/mL for apixaban, DOAC Dipstick test has a sensitivity of 97.2% and a positive predictive value of 89.5% at 30 ng/mL. No differences occurred between DXIs. Specificity and negative predictive value could not be determined due to the low number of true negative values. There were no differences in the interpretation of rivaroxaban and apixaban pad colors between observers (Kappa 1.0). Results show that DOAC Dipstick may be a useful tool for identifying DXIs in urine samples in an outpatient setting at a plasma threshold ≥ 30 ng/mL. Further studies should include patients treated with dabigatran, vitamin K antagonists, or other anticoagulants.
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Affiliation(s)
- Loula Papageorgiou
- Thrombosis Center, Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
- Sorbonne University, INSERM UMRS-938, Team "Cancer Vessels, Biology and Therapeutics," Group "Cancer - Angiogenesis - Thrombosis," Institut Universitaire de Cancérologie, Centre de Recherche Saint Antoine, Hôpital Saint Antoine, Assistance Publique - Hôpitaux de Paris, Paris, France
- Département Interdisciplinaire d'Organisation du Parcours Patient (DIOPP), Gustave Roussy, Villejuif, France
| | - Svetlana Hetjens
- Institute for Biometrie and Biiostatstics, Medical Faculty Mannheim University of Heidelberg, Mannheim, Germany
| | - Jawed Fareed
- Hemostasis and Thrombosis Research Laboratories, Cardiovascular Institute, Vascular Biology Loyola University Medical Center, Mannheim, Germany
| | - Sanny Auge
- Service de Médecine Interne, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
| | - Laetitia Tredler
- Service de Médecine Interne, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
| | - Job Harenberg
- Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
- DOASENSE GmbH, Heidelberg, Germany
| | - Christel Weiss
- Institute for Biometrie and Biiostatstics, Medical Faculty Mannheim University of Heidelberg, Mannheim, Germany
| | - Ismail Elalamy
- Thrombosis Center, Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
- Sorbonne University, INSERM UMRS-938, Team "Cancer Vessels, Biology and Therapeutics," Group "Cancer - Angiogenesis - Thrombosis," Institut Universitaire de Cancérologie, Centre de Recherche Saint Antoine, Hôpital Saint Antoine, Assistance Publique - Hôpitaux de Paris, Paris, France
- The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
- INNOVTE, FCRIN, Paris, France
| | - Grigorios T Gerotziafas
- Thrombosis Center, Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
- Sorbonne University, INSERM UMRS-938, Team "Cancer Vessels, Biology and Therapeutics," Group "Cancer - Angiogenesis - Thrombosis," Institut Universitaire de Cancérologie, Centre de Recherche Saint Antoine, Hôpital Saint Antoine, Assistance Publique - Hôpitaux de Paris, Paris, France
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Shaw JR, Li N, Nixon J, Moffat KA, Spyropoulos AC, Schulman S, Douketis JD. Coagulation assays and direct oral anticoagulant levels among patients having an elective surgery or procedure. J Thromb Haemost 2022; 20:2953-2963. [PMID: 36200348 DOI: 10.1111/jth.15901] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/27/2022] [Accepted: 09/29/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND The Perioperative Anticoagulation Use for Surgery Evaluation study prospectively evaluated a prespecified periprocedural interruption strategy of direct oral anticoagulants (DOACs) among patients with atrial fibrillation. Coagulation testing is widely available and frequently requested prior to invasive procedures. Coagulation assays display poor sensitivity to clinically relevant DOAC concentrations. OBJECTIVES Determine the utility of routinely available coagulation testing at predicting a DOAC concentration of <30 ng/ml among patients in the preprocedural setting. METHODS We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratio (LR+ and LR-) of a normal coagulation assay result for identifying patients with a preprocedural DOAC level < 30 ng/ml. RESULTS We identified weak or very weak correlations between coagulation assay results and DOAC levels in the preprocedural setting, except for a moderate correlation between the thrombin time (TT) and dabigatran concentrations (ρ = 0.68; p < .001). The prothrombin time (PT) and activated partial thromboplastin time (APTT) demonstrated modest sensitivity (78.9% to 88.2%) and PPVs (76.4% to 93.1%) but poor specificity (13.2% to 53.3%) and NPVs (16.3% to 30.2%) across all three DOACs. A normal TT was associated with 100% specificity and PPV values for a dabigatran level < 30 ng/ml. A normal APTT among patients on dabigatran was associated with an LR+ of 1.671 (95% confidence interval [CI] 1.297, 2.154) and an LR- of 0.395 (95% CI 0.207, 0.751) for levels <30 ng/ml. CONCLUSIONS The PT and APTT perform poorly at safely identifying patients with negligible DOAC levels in the preprocedural setting.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Na Li
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Computing and Software, McMaster University, Hamilton, Ontario, Canada
| | - Joanne Nixon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karen A Moffat
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | - Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, New York, USA
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics and Gynecology, I.M. Schenov First Moscow State Medical University, Moscow, Russia
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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9
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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10
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Aakerøy R, Stokes CL, Tomić M, Hegstad S, Kristoffersen AH, Ellekjær H, Schjøtt J, Spigset O, Helland A. Serum or Plasma for Quantification of Direct Oral Anticoagulants? Ther Drug Monit 2022; 44:578-584. [PMID: 35051972 PMCID: PMC9275836 DOI: 10.1097/ftd.0000000000000956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Direct oral anticoagulants are increasingly replacing vitamin K antagonists for prevention of stroke in patients with atrial fibrillation, partly owing to the lack of a need for routine monitoring. Therapeutic drug monitoring may still be warranted under certain circumstances. It is generally assumed that serum and plasma can be interchangeably used for this purpose. The aim of this study was to investigate possible differences between the serum, citrate-plasma, and ethylenediaminetetraacetic acid (EDTA)-plasma concentrations of apixaban and rivaroxaban in a larger patient group and their relation to factor X measurements. METHODS Plasma and serum samples were drawn during the same venipuncture from patients treated with apixaban or rivaroxaban. Drug levels were measured using ultrahigh-performance liquid chromatography combined with tandem mass spectrometry. Three sample matrices were obtained from 8 healthy volunteers for measurement of factor X antigen and activity. RESULTS Mean concentrations of apixaban and rivaroxaban were 16.8% and 36.6% higher in serum than in citrate-plasma, respectively (both P < 0.001). The corresponding differences in serum versus EDTA-plasma were 4.5% for apixaban and 13.1% for rivaroxaban (both P < 0.001). Factor X antigen measurements in citrate-plasma, EDTA-plasma, serum with clot activator, and serum without additives yielded comparable results, and factor X activity was significantly higher in serum than in plasma. CONCLUSIONS Apixaban and rivaroxaban concentrations were significantly higher in serum than in plasma. The difference was more pronounced with rivaroxaban and was larger between serum and citrate-plasma than between serum and EDTA-plasma. Higher factor X activity in serum may explain the observed concentration differences. The choice of matrix is, thus, important when interpreting therapeutic drug monitoring results and in research involving analyses of direct oral anticoagulants. The authors recommend citrate-plasma as the preferred matrix.
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Affiliation(s)
- Rachel Aakerøy
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Charlotte L. Stokes
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Marija Tomić
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
| | - Solfrid Hegstad
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
| | - Ann Helen Kristoffersen
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; and
- Stroke Unit, Department of Internal Medicine, St. Olav University Hospital, Trondheim, Norway
| | - Jan Schjøtt
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arne Helland
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
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11
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Merli GJ, Kraft WK, Eraso LH, Galanis T, Thomson LJ, Ouma GO, Viscusi E, Gong JZ, Lam E. Apixaban Discontinuation for Invasive Or major Surgical procedures (ADIOS): A prospective cohort study. Vasc Med 2021; 27:269-276. [PMID: 34809507 DOI: 10.1177/1358863x211047270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Apixaban pharmacokinetic properties and some clinical reports suggest cessation 48 hours prior to surgery is safe, but this has not been demonstrated in a naturalistic setting. We sought to measure the residual apixaban exposure in patients who had apixaban held as part of standard of care perioperative management. Methods: This was a prospective, observational study of patients in whom apixaban plasma concentration and anti-Xa activity were measured while at steady state apixaban dosing and again immediately prior to surgery. Clinical management of cessation and resumption of apixaban was at the discretion of the treating physician. Results: Paired blood samples were provided by 111 patients. Ninety-four percent (104/111) of patients had measured apixaban concentrations of ⩽ 30 ng/mL. Only one patient had a value > 50 ng/mL. The median time between the self-reported last dose and presurgery blood sampling was 76 hours (range 32-158) for those who achieved concentrations ⩽ 30 ng/mL and 59 hours (range 49-86) for those > 30 ng/mL. Measured anti-Xa activity correlated well with apixaban exposure. Clinically significant nonmajor bleeding was reported in one patient at 1 week postsurgery. There was one venous thromboembolic event and one stroke in the perioperative period. Conclusion: In a naturalistic setting with a heterogeneous patient population, apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure. ClinicalTrials.gov Identifier: NCT02935751.
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Affiliation(s)
- Geno J Merli
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Walter K Kraft
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
| | - Luis H Eraso
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Taki Galanis
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lynda J Thomson
- Department of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
| | - Geoffrey O Ouma
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jerald Z Gong
- Department of Pathology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Edwin Lam
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA.,Departments of Pharmacy, Clinical Pharmacokinetics Research Unit, National Institutes of Health, Bethesda, MD, USA
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12
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Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review. J Clin Med 2021; 10:jcm10112454. [PMID: 34205971 PMCID: PMC8198483 DOI: 10.3390/jcm10112454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022] Open
Abstract
About 15 years ago, Patient Blood Management (PBM) emerged as a new paradigm in perioperative medicine and rapidly found support of all major medical societies and government bodies. Blood products are precious, scarce and expensive and their use is frequently associated with adverse short- and long-term outcomes. Recommendations and guidelines on the topic are published in an increasing rate. The concept aims at using an evidence-based approach to rationalize transfusion practices by optimizing the patient's red blood cell mass in the pre-, intra- and postoperative periods. However, elegant as a concept, the implementation of a PBM program on an institutional level or even in a single surgical discipline like cardiac surgery, can be easier said than done. Many barriers, such as dogmatic ideas, logistics and lack of support from the medical and administrative departments need to be overcome and each center must find solutions to their specific problems. In this paper we present a narrative overview of the challenges and updated recommendations for the implementation of a PBM program in cardiac surgery.
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13
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Predictors of preprocedural direct oral anticoagulant levels in patients having an elective surgery or procedure. Blood Adv 2021; 4:3520-3527. [PMID: 32756938 DOI: 10.1182/bloodadvances.2020002335] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/01/2020] [Indexed: 12/21/2022] Open
Abstract
The Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) study prospectively evaluated a prespecified periprocedural-interruption strategy of direct oral anticoagulants (DOACs) among patients with atrial fibrillation. Logistic regression analyses were performed to identify clinical parameters associated with residual DOAC levels ≥30 ng/mL or ≥50 ng/mL. Patients undergoing low-bleed-risk procedures were more likely to have residual levels of ≥30 ng/mL and ≥50 ng/mL. For low-risk procedures, age ≥75 years, female sex, a creatinine clearance (CrCl) <50 mL/min, and an interruption of <36 hours were associated with a greater likelihood of levels ≥30 ng/mL, whereas age ≥75 years, female sex, a CrCl of <50 mL/min, and standard DOAC dosing were associated with levels ≥50 ng/mL. For high-risk procedures, weight of <70 kg, CrCl <50 mL/min, and standard DOAC dosing were associated with residual levels ≥30 ng/mL, whereas female sex was associated with levels ≥50 ng/mL. For low-risk procedures, apixaban was associated with a higher likelihood of levels ≥30 ng/mL as compared with dabigatran (P = .0019) and of levels ≥50 ng/mL when compared with rivaroxaban (P = .0003). For high-risk procedures, apixaban was marginally associated with a higher likelihood of residual levels ≥30 ng/mL when compared with dabigatran (P = .05), whereas rivaroxaban was associated with a higher likelihood of levels ≥30 ng/mL as compared with apixaban. Further study is required to determine whether adjustments to perioperative plans based on these clinical parameters could result in a lower risk of residual DOAC levels. The PAUSE trial was registered at www.clinicaltrials.gov as #NCT2228798.
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14
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Abstract
Decisions surrounding periprocedural anticoagulation management must balance thromboembolic and procedural bleed risk. The interruption of both warfarin and DOACs requires consideration of anticoagulant pharmacokinetics, procedural bleed risk and patient characteristics. There is a diminishing role for periprocedural bridging LMWH overall and no role for bridging LMWH for the procedural interruption of DOACs. A clinical approach to perioperative DOAC management based on operative bleeding risk and renal function is safe and effective, and at present, is preferred over preprocedural DOAC levels testing. Clear communication of the anticoagulation interruption plan to both the patient and the patient's care team is essential.
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Affiliation(s)
- Joseph R Shaw
- Ottawa Blood Disease Center, Division of Hematology, The Ottawa Hospital, Box 206, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada. https://twitter.com/JRand083
| | - Eric Kaplovitch
- Department of Medicine, University Health Network, The University of Toronto, 585 University Avenue, Norman Urquhart Building, 7th Floor, Room 739, Toronto, Ontario M5G 2N2, Canada. https://twitter.com/kaplovitch
| | - James Douketis
- Department of Medicine, Division of General Internal Medicine, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L4N 4A6, Canada; Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L4N 4A6, Canada.
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15
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Metze M, Pfrepper C, Klöter T, Stöbe S, Siegemund R, Siegemund T, Edel E, Laufs U, Petros S. Inhibition of thrombin generation 12 hours after intake of direct oral anticoagulants. Res Pract Thromb Haemost 2020; 4:610-618. [PMID: 32548560 PMCID: PMC7292666 DOI: 10.1002/rth2.12332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/12/2020] [Accepted: 02/02/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The residual antithrombotic activity 12 hours after intake of direct oral anticoagulants (DOACs) is of clinical relevance in the setting of bleeding or urgent surgery. OBJECTIVE To evaluate the effects of DOACs on thrombin generation 12 hours after DOAC intake in comparison to baseline and a healthy control group. METHODS Eighty patients were recruited, 20 patients for each approved DOAC: apixaban, edoxaban, rivaroxaban, and dabigatran. The patients were either to be put on anticoagulation for the first time or had stopped taking oral anticoagulation for at least 48 hours. Blood plasma was sampled before (baseline) and 12 hours after starting DOAC for quantification of drug levels and thrombin generation assayed using an automated system (ST Genesia). Sixty-one blood donors served as control group. RESULTS The factor Xa inhibitors significantly increased lag time (137%-219%) and reduced thrombin peak (47%-76%) and velocity index (17%-44%) after 12 hours compared to baseline. Dabigatran showed prolongation of lag time to 133% and time to peak to 119%. All patients had residual antithrombotic activity, with reduced thrombin generation parameters 12 hours after DOAC intake compared to baseline and to the healthy control group. This effect remained significant in patients with low residual DOAC plasma levels <50 ng/mL. CONCLUSION Thrombin generation remains reduced 12 hours after DOAC intake. While thrombin peak is particularly modified by factor Xa inhibitors, all DOACs prolong the lag time and time to thrombin peak. In the setting of bleeding or urgent surgery, the automated thrombin generation assay may assist in decision making and antidote administration.
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Affiliation(s)
- Michael Metze
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Christian Pfrepper
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Tristan Klöter
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Stephan Stöbe
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Roland Siegemund
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Thomas Siegemund
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Elvira Edel
- Institute of Transfusion MedicineUniversity Hospital LeipzigLeipzigGermany
| | - Ulrich Laufs
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Sirak Petros
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
- Medical ICUUniversity Hospital LeipzigLeipzigGermany
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16
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Fox V, Kleikamp A, Dittrich M, Zittermann A, Flieder T, Knabbe C, Gummert J, Birschmann I. Direct oral anticoagulants and cardiac surgery: A descriptive study of preoperative management and postoperative outcomes. J Thorac Cardiovasc Surg 2020; 161:1864-1874.e2. [PMID: 31982117 DOI: 10.1016/j.jtcvs.2019.11.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 11/26/2019] [Accepted: 11/26/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Recommendations for perioperative management of direct oral anticoagulant (DOAC) treatment in cardiac surgery are lacking. To establish a standardized approach for these patients, we compared hemorrhagic complications and clinical outcomes in patients on DOAC medication, patients on vitamin K antagonists (VKA), and patients without preoperative anticoagulation. METHODS All 3 groups underwent major cardiac surgery and were retrospectively analyzed: patients on DOAC were advised to take their last DOAC dose 4 days before hospital admission, and DOAC plasma levels were measured the day before surgery. In patients with plasma levels of >30 ng/mL, surgery was postponed until plasma level was below this threshold level. Postoperative chest tube drainage, bleeding complications, use of blood products, and thromboembolic events were collected for all groups. RESULTS A total of 5439 patients no anticoagulation, 239 patients on VKA, and 487 patients on DOAC medication were included between April 2014 and July 2017. Adjusted postoperative chest tube drainage did not differ between the DOAC and VKA groups for the strategy applied in this study (380 mL/12 hours vs 360 mL/12 hours). Moreover, secondary endpoint measures, such as rethoracotomy (30 [6.16%] vs 15 [6.28%]), 30-day-mortality 12 [2.46%] vs 7 [2.93%]), blood-product use, and stroke, were not significantly different through implementation of our standardized study management (P > .05). CONCLUSIONS Our standardized management for perioperative discontinuation of DOAC therapy may provide a safe approach to minimize hemorrhagic complications in cardiac surgery in patients on DOACs.
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Affiliation(s)
- Vanessa Fox
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Ariane Kleikamp
- Klinik für Thorax- und Kardiovaskularchirurgie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Marcus Dittrich
- Department of Bioinformatics, Biocenter, University, Würzburg, Germany; Institute of Human Genetics, University, Würzburg, Germany
| | - Armin Zittermann
- Klinik für Thorax- und Kardiovaskularchirurgie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Tobias Flieder
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Cornelius Knabbe
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Jan Gummert
- Klinik für Thorax- und Kardiovaskularchirurgie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Ingvild Birschmann
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany.
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17
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Ebner M, Birschmann I, Peter A, Härtig F, Spencer C, Kuhn J, Rupp A, Blumenstock G, Zuern CS, Ziemann U, Poli S. Limitations of Specific Coagulation Tests for Direct Oral Anticoagulants: A Critical Analysis. J Am Heart Assoc 2019; 7:e009807. [PMID: 30371316 PMCID: PMC6404908 DOI: 10.1161/jaha.118.009807] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background During treatment with direct oral anticoagulants (DOAC), coagulation assessment is required before thrombolysis, surgery, and if anticoagulation reversal is evaluated. Limited data support the accuracy of DOAC‐specific coagulation assays around the current safe‐for‐treatment threshold of 30 ng/mL. Methods and Results In 481 samples obtained from 96 patients enrolled at a single center, DOAC concentrations were measured using Hemoclot direct thrombin inhibitor assay, Biophen direct thrombin inhibitor assay or ecarin clotting time for dabigatran, chromogenic anti‐Xa assay (AXA) for factor Xa inhibitors (rivaroxaban, apixaban) and ultraperformance liquid chromatography–tandem mass spectrometry as reference. All dabigatran‐specific assays had high sensitivity to concentrations >30 ng/mL, but specificity was lower for Hemoclot direct thrombin inhibitor assay (78.2%) than for Biophen direct thrombin inhibitor assay (98.9%) and ecarin clotting time (94.6%). AXA provided high sensitivity and specificity for rivaroxaban, but low sensitivity for apixaban (73.8%; concentrations up to 82 ng/mL were misclassified as <30 ng/mL). If no DOAC‐specific calibration for AXA is available, results 2‐fold above the upper limit of normal indicate relevant rivaroxaban concentrations. For apixaban, all elevated results should raise suspicion of relevant anticoagulation. Conclusions DOAC‐specific tests differ considerably in diagnostic performance for concentrations close to the currently accepted safe‐for‐treatment threshold. Compared with Biophen direct thrombin inhibitor assay and ecarin clotting time, limited specificity of Hemoclot direct thrombin inhibitor assay poses a high risk of unnecessary anticoagulation reversal or treatment delays in patients on dabigatran. While AXA accurately detected rivaroxaban, the impact of low apixaban levels on the assay was weak. Hence, AXA results need to be interpreted with extreme caution when used to assess hemostatic function in patients on apixaban. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifiers: NCT02371044, NCT02371070.
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Affiliation(s)
- Matthias Ebner
- 1 Department of Internal Medicine and Cardiology Charité University Medicine Berlin Campus Virchow Klinikum Berlin Germany.,2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Ingvild Birschmann
- 3 Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center Ruhr University Bad Oeynhausen Germany
| | - Andreas Peter
- 4 Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry Department of Internal Medicine University Hospital Tübingen Germany.,5 Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich University of Tübingen Germany.,6 German Centre for Diabetes Research (DZD) Neuherberg Germany
| | - Florian Härtig
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Charlotte Spencer
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Joachim Kuhn
- 3 Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center Ruhr University Bad Oeynhausen Germany
| | - André Rupp
- 7 Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Gunnar Blumenstock
- 8 Department of Clinical Epidemiology and Applied Biometry University of Tübingen Germany
| | - Christine S Zuern
- 9 Department of Cardiology and Cardiovascular Medicine University Hospital Tübingen Germany.,10 Department of Cardiology and Cardiovascular Research Institute Basel (CRIB) University Hospital Basel Switzerland
| | - Ulf Ziemann
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Sven Poli
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
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18
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Monitoring of low dabigatran concentrations: diagnostic performance at clinically relevant decision thresholds. J Thromb Thrombolysis 2019; 49:457-467. [PMID: 31691890 DOI: 10.1007/s11239-019-01981-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The direct oral anticoagulant dabigatran does not require therapeutic drug monitoring, however emergency measurements are gaining importance. Current assays feature good performance at intermediate and high dabigatran concentrations but show limited accuracy at low concentrations. This area requires more attention as clinical decision threshold values currently lie at 30 and 50 ng/ml. The objective of the study was to evaluate and compare diagnostic performance of dabigatran assays at these thresholds. Dabigatran concentrations of 293 plasma samples taken from 50 patients were measured with the INNOVANCE direct thrombin inhibitor assay (DTI) from Siemens, the Biophen direct thrombin inhibitor assay (BDTI), the BDTI using a low range calibrator (BDTI-low), the Hemoclot direct thrombin inhibitor assay (HTI) and an ecarin clotting time assay (ECT). Assay results were compared to ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS), and test characteristics were calculated for thresholds of 30 and 50 ng/ml. DTI, BDTI-low and ECT showed very strong correlation and high agreement with UPLC-MS/MS and an improved determination of low dabigatran concentrations. ROC curve analyses revealed very high accuracy at the 30/50 ng/ml thresholds for DTI (AUC = 0.989/0.995), BDTI-low (AUC = 0.980/0.991) and ECT (AUC = 0.990/0.996) measurements. Sensitivity and specificity in detecting were calculated for DTI (98/92%), BDTI-low (87/95%), ECT (97/96%), BDTI (99/82%) and HTI (86/89%) measurements. Compared to the previously available HTI and BDTI, both novel assays, DTI and BDTI-low, reliably determine low dabigatran plasma concentrations around the clinical decision thresholds with very high sensitivity and specificity.
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19
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Kaserer A, Kiavialaitis GE, Braun J, Schedler A, Stein P, Rössler J, Spahn DR, Studt JD. Impact of rivaroxaban plasma concentration on perioperative red blood cell loss. Transfusion 2019; 60:197-205. [PMID: 31682296 DOI: 10.1111/trf.15560] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/26/2019] [Accepted: 09/26/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND This study investigates the impact of preoperative calculated rivaroxaban (RXA) plasma concentration on perioperative red blood cell (RBC) loss. STUDY DESIGN AND METHODS In this retrospective single-center study, we identified patients with RXA intake according to a preoperative determination of RXA levels within 96 hours before surgery. RXA plasma concentration at the beginning of surgery was then calculated from the last RXA intake using a single-compartment pharmacokinetic model with four categories of RXA concentration (≤20, 21-50, 51-100, and >100 μg/L). Patients were classified into surgery with high (≥500 mL) or low (<500 mL) expected blood loss. Perioperative bleeding was determined by calculating RBC loss. RESULTS We analyzed 308 surgical interventions in 298 patients during the period from January 2012 to July 2018. Among patients undergoing surgery with low expected blood loss, RBC loss varied from 164 mL (standard deviation [SD], 189) to 302 mL (SD, 397) (p = 0.66), and no association of calculated RXA concentration with RBC loss was observed. In patients undergoing surgery with high expected blood loss, we found a significant correlation of calculated RXA concentration with RBC loss (Pearson's correlation coefficient, 0.29; p = 0.002). RBC loss increased with rising RXA concentration from 575 mL (SD, 365) at RXA concentration of 20 μg/L or less up to 1400 mL (SD, 1300) at RXA concentration greater than 100 μg/L. RXA concentration greater than 100 μg/L was associated with a significant increase of in RBC loss of 840 mL (95% confidence interval, 360-1300; p < 0.001). Transfusion of RBC and fresh frozen plasma units tended to increase in patients with RXA concentrations greater than 100 μg/L. The proportion of patients treated with prothrombin complex concentrate and coagulation factor XIII concentrate increased significantly with higher RXA concentrations. CONCLUSION Only in surgery with high expected blood loss, a calculated RXA concentration of greater than 100 μg/L was associated with a significant increase of perioperative RBC loss.
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Affiliation(s)
- Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Julia Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Andreas Schedler
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Philipp Stein
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Jan-Dirk Studt
- Division of Hematology, University and University Hospital Zurich, Zurich, Switzerland
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20
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Severe Enoral Bleeding with a Direct Oral Anticoagulant after Tooth Extraction and Heparin Bridging Treatment. Case Rep Emerg Med 2019; 2019:6208604. [PMID: 31781415 PMCID: PMC6875271 DOI: 10.1155/2019/6208604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/18/2019] [Accepted: 08/08/2019] [Indexed: 12/04/2022] Open
Abstract
Background The number of patients receiving direct oral anticoagulants (DOACs) is increasing, however, this treatment is associated with the risk of bleeding. More than 10 percent of patients on DOACs have to interrupt their anticoagulation for an invasive procedure every year. For this reason, the correct management of DOACs in the perioperative setting is mandatory. Case Presentation An 81-year-old male patient, with known impaired renal function, presented to our emergency department with a severe enoral bleeding after tooth extraction. The DOAC therapy—indicated by known atrial fibrillation—was interrupted perioperatively and bridged with Low Molecular Weight Heparin (LMWH). The acute bleeding was stopped by local surgery. The factors contributing to the bleeding complication were bridging of DOAC treatment, together with prolonged drug action in chronic kidney disease. Conclusion In order to decide whether it is necessary to stop DOAC medication for tooth extraction, it is important to carefully weigh up the individual risks of bleeding and thrombosis. If DOAC therapy is interrupted, bridging should be reserved for thromboembolic high-risk situations. Particular caution is required in patients with impaired kidney function, due to the risk of accumulation and prolonged anticoagulant effect of both DOACs and LMWH.
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Smadja DM, Gendron N, Sanchez O. [Who should supervise anticoagulant treatment and how?]. Rev Mal Respir 2019; 38 Suppl 1:e113-e119. [PMID: 31611030 DOI: 10.1016/j.rmr.2019.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- D-M Smadja
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Inserm UMR-S1140, service d'hématologie, laboratoire de recherche biochirurgicale, Fondation Carpentier, hôpital européen Georges-Pompidou, université Paris Descartes, Sorbonne Paris Cité, hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France
| | - N Gendron
- Inserm UMR 1148, laboratoire d'hématologie, hôpital Bichat-Claude Bernard, université Paris Diderot, Sorbonne Paris Cité, AP-HP, 75018 Paris, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, université de Paris, Sorbonne Paris Cité, Assistance publique des Hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, France; Innovations thérapeutiques en hémostase, Inserm UMRS 1140, 75006 Paris, France.
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Nazha B, Pandya B, Cohen J, Zhang M, Lopes RD, Garcia DA, Sherwood MW, Spyropoulos AC. Periprocedural Outcomes of Direct Oral Anticoagulants Versus Warfarin in Nonvalvular Atrial Fibrillation. Circulation 2019; 138:1402-1411. [PMID: 29794081 DOI: 10.1161/circulationaha.117.031457] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are surpassing warfarin as the anticoagulant of choice for stroke prevention in nonvalvular atrial fibrillation. DOAC outcomes in elective periprocedural settings have not been well elucidated and remain a source of concern for clinicians. The aim of this meta-analysis was to evaluate the periprocedural safety and efficacy of DOACs versus warfarin in patients with nonvalvular atrial fibrillation. METHODS We reviewed the literature for data from phase III randomized controlled trials comparing DOACs with warfarin in the periprocedural period among patients with nonvalvular atrial fibrillation. Substudies from 4 trials (RE-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy], ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibitor Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation], ARISTOTLE [Apixaban for the Prevention of Stroke in Subjects With Atrial Fibrillation], and ENGAGE-AF [Effective Anticoagulation With Factor xA Next Generation in Atrial Fibrillation]) were included in the meta-analysis. DOACs as a group and warfarin were compared in terms of the 30-day pooled risk for stroke/systemic embolism, major bleeding, and death, according to whether the study drug was interrupted or not periprocedurally. The overall relative risk (RR) was estimated with a random-effects model. The I2 test was used to assess heterogeneity in RR among the studies. RESULTS In the uninterrupted anticoagulant strategy, there were no differences in the rates of stroke/systemic embolism (pooled risk, 0.6% [29 events/4519 procedures] versus 1.1% [31/2971]; RR, 0.70; 95% confidence interval [CI], 0.41-1.18) and death (1.4% versus 1.8%; RR, 0.77; 95% CI, 0.53-1.12) between DOACs and warfarin and significantly fewer major bleeding events (2.0% versus 3.3%; RR, 0.62; 95% CI, 0.47-0.82) with DOACs compared to warfarin. Under an interrupted strategy, there was no significant difference between DOACs versus warfarin for stroke/systemic embolism (0.4% [41/9260] versus 0.5% [31/7168]; RR, 0.95; 95% CI, 0.59-1.55), major bleeding (2.1% versus 2.0%; RR, 1.05; 95% CI, 0.85-1.30), and death (0.7% versus 0.6%; RR, 1.24; 95% CI, 0.76-2.04). The studies were homogeneous ( I2=0.0%) for all calculated pooled associations except for the RR of death in the interrupted strategy ( I2=26.3%). CONCLUSIONS The short-term safety and efficacy of DOACs and warfarin are not different in patients with nonvalvular atrial fibrillation periprocedurally. Under an uninterrupted anticoagulation strategy, DOACs are associated with a 38% lower risk of major bleeding compared with warfarin.
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Affiliation(s)
- Bassel Nazha
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA (B.N.)
| | - Bhavi Pandya
- Division of Cardiology, Staten Island University Hospital-Northwell Health, NY (B.P.)
| | - Jessica Cohen
- Division of Hospital Medicine, Northwell Health at North Shore University Hospital, Manhasset, NY (J.C.)
| | - Meng Zhang
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY (M.Z., A.C.S.)
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.)
| | - David A Garcia
- Department of Medicine, Division of Hematology, University of Washington School of Medicine, Seattle (D.A.G.)
| | | | - Alex C Spyropoulos
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY (M.Z., A.C.S.).,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY (A.C.S.).,Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York, NY (A.C.S.)
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23
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Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J, Shehab N, Mock J, Myers T, Dentali F, Crowther MA, Agarwal A, Bhatt M, Khatib R, Riva JJ, Zhang Y, Guyatt G. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257-3291. [PMID: 30482765 PMCID: PMC6258922 DOI: 10.1182/bloodadvances.2018024893] [Citation(s) in RCA: 304] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants. CONCLUSIONS Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.
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Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation and Anemia Service, Kaiser Permanente Colorado, Aurora, CO
| | - Jack Ansell
- School of Medicine, Hofstra Northwell, Hempstead, NY
| | - Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jane Skov
- Unit for Health Promotion Research, Department of Public Health, University of Southern Denmark, Esbjerg, Denmark
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL; and
| | - John J Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Albaladejo P, Pernod G, Godier A, de Maistre E, Rosencher N, Mas JL, Fontana P, Samama CM, Steib A, Schlumberger S, Marret E, Roullet S, Susen S, Madi-Jebara S, Nguyen P, Schved JF, Bonhomme F, Sié P. Management of bleeding and emergency invasive procedures in patients on dabigatran: Updated guidelines from the French Working Group on Perioperative Haemostasis (GIHP) – September 2016. Anaesth Crit Care Pain Med 2018; 37:391-399. [DOI: 10.1016/j.accpm.2018.04.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 11/25/2022]
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Douxfils J, Ageno W, Samama CM, Lessire S, Ten Cate H, Verhamme P, Dogné JM, Mullier F. Laboratory testing in patients treated with direct oral anticoagulants: a practical guide for clinicians. J Thromb Haemost 2018; 16:209-219. [PMID: 29193737 DOI: 10.1111/jth.13912] [Citation(s) in RCA: 232] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Indexed: 11/30/2022]
Abstract
Click to hear Dr Baglin's perspective on the role of the laboratory in treatment with new oral anticoagulants SUMMARY: One of the key benefits of the direct oral anticoagulants (DOACs) is that they do not require routine laboratory monitoring. Nevertheless, assessment of DOAC exposure and anticoagulant effects may become useful in various clinical scenarios. The five approved DOACs (apixaban, betrixaban, dabigatran etexilate, edoxaban and rivaroxaban) have different characteristics impacting assay selection and the interpretation of results. This article provides an updated overview on (i) which test to use (and their advantages and limitations), (ii) when to assay DOAC levels, (iii) how to interpret the results relating to bleeding risk, emergency situations and perioperative management, and (iv) what is the impact of DOACs on routine and specialized coagulation assays. Assays for anti-Xa or anti-IIa activity are the preferred methods when quantitative information is useful, although the situations in which to test for DOAC levels are still debated. Different reagent sensitivities and variabilities in laboratory calibrations impact assay results. International calibration standards for all specific tests for each DOAC are needed to reduce the inter-laboratory variability and allow inter-study comparisons. The impact of the DOACs on hemostasis testing may cause false-positive or false-negative results; however, these can be minimized by using specific assays and collecting blood samples at trough concentrations. Finally, prospective clinical trials are needed to validate the safety and efficacy of proposed laboratory thresholds in relation to clinical decisions. We offer recommendations on the tests to use for measuring DOACs and practical guidance on laboratory testing to help patient management and avoid diagnostic errors.
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Affiliation(s)
- J Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Centre (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
- Qualiblood s.a., Namur, Belgium
| | - W Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - C-M Samama
- Cochin University Hospital, Department of Anaesthesiology and Intensive Care, Université Paris Descartes, Paris, France
| | - S Lessire
- Department of Anaesthesiology, Namur Thrombosis and Haemostasis Centre (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - H Ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre and Cardiovascular Research Institute (CARIM), Maastricht, the Netherlands
| | - P Verhamme
- Department of Cardiovascular Sciences, Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - J-M Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Centre (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - F Mullier
- CHU UCL Namur, Laboratory Hematology, Namur Thrombosis and Haemostasis Centre (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, Yvoir, Belgium
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Residual rivaroxaban exposure after discontinuation of anticoagulant therapy in patients undergoing cardiac catheterization. Eur J Clin Pharmacol 2018; 74:611-618. [PMID: 29376194 DOI: 10.1007/s00228-018-2421-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 01/18/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Patients treated with direct oral anticoagulants (DOACs) frequently undergo interventional procedures requiring temporary discontinuation of anticoagulant therapy. Little is known about remaining peri-procedural exposure to rivaroxaban in real-world patients. METHODS Fifty-six patients with rivaroxaban treatment and scheduled cardiac catheterization were included in this prospective, observational, and single-center study. Rivaroxaban concentrations were determined by LC-MS/MS and a chromogenic anti-Xa assay. Population pharmacokinetic modeling was carried out on LC-MS/MS concentration data using NONMEM software, and results were applied to Monte Carlo simulations to predict appropriate rivaroxaban discontinuation intervals. RESULTS Rivaroxaban concentrations ranged from <LLOQ to 300.6 ng/ml at the time of admission to hospital and from <LLOQ to 55.5 ng/ml at the beginning of the procedure. Times since last rivaroxaban intake were (mean ± SD) 51.0 ± 31.7 h (admission) and 85.5 ± 36.8 h (start catheterization). LC-MS/MS and anti-Xa assay results were in good agreement (r = 0.958); however, the anti-Xa assay may underestimate low rivaroxaban concentrations and overestimate rivaroxaban exposure when performed on plasma samples contaminated with heparins. Pharmacokinetics of rivaroxaban were adequately described, and simulations predicted that 95% of patients will have rivaroxaban concentrations ≤ 28.4 ng/ml (15 mg dose group) and ≤ 31.9 ng/ml (20 mg dose group) after 48 h of discontinuation. CONCLUSIONS In the majority of patients, rivaroxaban plasma concentrations dropped below 30 ng/ml after 48 h of treatment discontinuation which is considered hemostatically safe before surgery with high bleeding risk. For accurate determination of low rivaroxaban concentrations, LC-MS/MS is the preferred choice.
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Jaffer IH, Chan N, Roberts R, Fredenburgh JC, Eikelboom JW, Weitz JI. Comparison of the ecarin chromogenic assay and diluted thrombin time for quantification of dabigatran concentrations. J Thromb Haemost 2017; 15:2377-2387. [PMID: 28976630 DOI: 10.1111/jth.13857] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Indexed: 11/28/2022]
Abstract
Essentials Routine monitoring is unnecessary but measuring dabigatran levels is helpful in certain situations. We compared ecarin chromogenic assay (STA-ECA-II) and dilute thrombin time (dTT) in patient samples. Both tests provided accurate measurements over a wide range of dabigatran concentrations. Adoption of STA-ECA-II and dTT into routine clinical practice will improve patient care. SUMMARY Background Although routine coagulation monitoring is unnecessary, measuring plasma dabigatran concentrations can be useful for detecting drug accumulation in renal failure or overdose, assessing the contribution of dabigatran to serious bleeding, planning the timing of urgent surgery or intervention, or determining the suitability for thrombolytic therapy for acute ischemic stroke. Dabigatran concentrations can be quantified using chromogenic or clot-based tests, such as the ecarin chromogenic assay (ECA) and the diluted thrombin time (dTT), respectively. Objective The purpose of this study was to compare the results of these assays with dabigatran concentrations measured by the reference standard of mass spectrometry in samples from 50 dabigatran-treated patients collected at peak and trough after at least 4 months of drug intake. Methods Drug levels measured with either the STA Ecarin Chromogenic Assay-II (STA-ECA-II) or dTT were linearly correlated with those determined by mass spectrometry over a wide range of concentrations. Results and Conclusions For detection of levels below 50 ng mL-1 both tests have specificities of at least 96%, suggesting that they accurately detect even low levels of drug. Therefore, regardless of whether a chromogenic or clot-based platform is preferred, the STA-ECA-II and dTT are useful tests for measuring dabigatran concentrations. Unfortunately, neither test is licensed by the United States Food and Drug Administration. Although approved in other jurisdictions, the dTT and STA-ECA-II are not widely or rapidly available in most hospitals. Therefore, cooperation between regulators and hospitals is urgently needed to render these tests readily available to inform patient care.
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Affiliation(s)
- I H Jaffer
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
- Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
| | - N Chan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - R Roberts
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - J C Fredenburgh
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - J W Eikelboom
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - J I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
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Godier A, Dincq AS, Martin AC, Radu A, Leblanc I, Antona M, Vasse M, Golmard JL, Mullier F, Gouin-Thibault I. Predictors of pre-procedural concentrations of direct oral anticoagulants: a prospective multicentre study. Eur Heart J 2017; 38:2431-2439. [DOI: 10.1093/eurheartj/ehx403] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 06/29/2017] [Indexed: 12/20/2022] Open
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Deutsch D, Boustière C, Ferrari E, Albaladejo P, Morange PE, Benamouzig R. Direct oral anticoagulants and digestive bleeding: therapeutic management and preventive measures. Therap Adv Gastroenterol 2017; 10:495-505. [PMID: 28567119 PMCID: PMC5424873 DOI: 10.1177/1756283x17702092] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 02/15/2017] [Indexed: 02/04/2023] Open
Abstract
The use of direct oral anticoagulants (DOACs) was an important step forward in the management of atrial fibrillation and venous thromboembolism (VTE). The DOACs, anti-IIa for dabigatran and anti-Xa for rivaroxaban, apixaban and edoxaban, all have a rapid onset of action and a short half life. There is no need for routine hemostasis testing for treatment monitoring of a DOAC. Compared with vitamin K antagonists (VKAs), DOACs may increase the risk of gastrointestinal bleeding (relative risk 1.25). Withholding the DOAC treatment, evaluating the time of the last intake and estimating the patient's renal function are the first steps in the management of gastrointestinal bleeding. For patients without impaired renal function, achieving low coagulation takes around 24 h after the last intake of a DOAC. The use of DOAC antagonists will be helpful in controlling bleeding in the most severe and urgent situations. Idarucizumab is available for clinical use for dabigatran and andexanet is currently being reviewed by drug agencies for rivaroxaban, apixaban and edoxaban. It is important to assess the bleeding risk associated with the planned procedure, and the patient's renal function before withholding DOAC therapy for a scheduled intervention. It is mandatory to strengthen the local hemostasis strategies in DOAC-treated patients undergoing a therapeutic endoscopic procedure. Resuming or not resuming anticoagulation with a DOAC after bleeding or a risky procedure depends on the thrombotic and bleeding risk as well as the procedure involved. This discussion should always involve the cardiologist and decisions should be taken by a pluridisciplinary team.
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Affiliation(s)
| | | | - Emile Ferrari
- Centre Hospitalier Universitaire de Nice, Nice, Provence-Alpes-Côte d’Azur, France
| | - Pierre Albaladejo
- Centre Hospitalier Universitaire de Grenoble, Grenoble, Rhône-Alpes, France
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Dubois V, Dincq AS, Douxfils J, Ickx B, Samama CM, Dogné JM, Gourdin M, Chatelain B, Mullier F, Lessire S. Perioperative management of patients on direct oral anticoagulants. Thromb J 2017; 15:14. [PMID: 28515674 PMCID: PMC5433145 DOI: 10.1186/s12959-017-0137-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 05/04/2017] [Indexed: 12/31/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10-15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure. As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.
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Affiliation(s)
- Virginie Dubois
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Brigitte Ickx
- Université Libre de Bruxelles, Erasme University Hospital,Department of Anesthesiology, Brussels, Belgium
| | - Charles-Marc Samama
- Université Paris Descartes, Cochin University Hospital,Department of Anesthesiology and Intensive Care, Paris, France
| | - Jean-Michel Dogné
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Maximilien Gourdin
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Bernard Chatelain
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - Sarah Lessire
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
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Point-of-care testing for emergency assessment of coagulation in patients treated with direct oral anticoagulants. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:32. [PMID: 28196509 PMCID: PMC5309971 DOI: 10.1186/s13054-017-1619-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 01/27/2017] [Indexed: 01/24/2023]
Abstract
Background Point-of-care testing (POCT) of coagulation has been proven to be of great value in accelerating emergency treatment. Specific POCT for direct oral anticoagulants (DOAC) is not available, but the effects of DOAC on established POCT have been described. We aimed to determine the diagnostic accuracy of Hemochron® Signature coagulation POCT to qualitatively rule out relevant concentrations of apixaban, rivaroxaban, and dabigatran in real-life patients. Methods We enrolled 68 patients receiving apixaban, rivaroxaban, or dabigatran and obtained blood samples at six pre-specified time points. Coagulation testing was performed using prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), and activated clotting time (ACT+ and ACT-low range) POCT cards. For comparison, laboratory-based assays of diluted thrombin time (Hemoclot) and anti-Xa activity were conducted. DOAC concentrations were determined by liquid chromatography-tandem mass spectrometry. Results Four hundred and three samples were collected. POCT results of PT/INR and ACT+ correlated with both rivaroxaban and dabigatran concentrations. Insufficient correlation was found for apixaban. Rivaroxaban concentrations at <30 and <100 ng/mL were detected with >95% specificity at PT/INR POCT ≤1.0 and ≤1.1 and ACT+ POCT ≤120 and ≤130 s. Dabigatran concentrations at <30 and <50 ng/mL were detected with >95% specificity at PT/INR POCT ≤1.1 and ≤1.2 and ACT+ POCT ≤100 s. Conclusions Hemochron® Signature POCT can be a fast and reliable alternative for guiding emergency treatment during rivaroxaban and dabigatran therapy. It allows the rapid identification of a relevant fraction of patients that can be treated immediately without the need to await the results of much slower laboratory-based coagulation tests. Trial registration Unique identifier, NCT02371070. Retrospectively registered on 18 February 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1619-z) contains supplementary material, which is available to authorized users.
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Tripodi A. To measure or not to measure direct oral anticoagulants before surgery or invasive procedures: reply. J Thromb Haemost 2016; 14:2559-2561. [PMID: 27662099 DOI: 10.1111/jth.13513] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Clinical Sciences and Community Health, Università degli Studi di Milano and IRCCS Cà Granda Maggiore Hospital, Milan, Italy
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Spyropoulos AC, Al-Badri A, Sherwood MW, Douketis JD. To measure or not to measure direct oral anticoagulants before surgery or invasive procedures: comment. J Thromb Haemost 2016; 14:2556-2559. [PMID: 27622661 DOI: 10.1111/jth.13505] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 12/21/2022]
Affiliation(s)
- A C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra Northwell School of Medicine, Northwell Health System, Manhasset, NY, USA
| | - A Al-Badri
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - M W Sherwood
- Duke Clinical Research Institute, Durham, NC, USA
| | - J D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Lessire S, Douxfils J, Pochet L, Dincq AS, Larock AS, Gourdin M, Dogné JM, Chatelain B, Mullier F. Estimation of Rivaroxaban Plasma Concentrations in the Perioperative Setting in Patients With or Without Heparin Bridging. Clin Appl Thromb Hemost 2016; 24:129-138. [PMID: 27811211 DOI: 10.1177/1076029616675968] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Estimation of residual rivaroxaban plasma concentrations may be requested before invasive procedures and some patients at high thromboembolic risk will have a bridging therapy with heparins when rivaroxaban is interrupted. OBJECTIVE The objective of this study was to assess the performance of the STA-Liquid Anti-Xa assay (STA LAX) and the low and normal procedures of the Biophen Direct Factor Xa Inhibitors (DiXaI) assay, in patients with and without bridging with low-molecular-weight heparins (LMWHs). MATERIALS AND METHODS Seventy-nine blood samples were collected from 77 patients on rivaroxaban at CTROUGH or before an invasive procedure. Rivaroxaban plasma concentrations were estimated using Biophen DiXaI, Biophen DiXaI LOW, and STA LAX and compared to liquid chromatography coupled with mass spectrometry (LC-MS/MS) measurements. Stratifications were performed according to heparin bridging. RESULTS The Biophen DiXaI LOW and STA LAX showed better correlation with LC-MS/MS measurements than Biophen DiXaI in patients not bridged with LMWH (R: 0.97, 0.96, and 0.91, respectively). However, the performance of Biophen DiXaI LOW and STA LAX decreased when residual LMWH activity was present (R: 0.18 and 0.19 respectively) demonstrating that these tests are not specific to rivaroxaban. CONCLUSION In patients not bridged with LMWH, we suggest to use the Biophen DiXaI LOW and STA LAX for the estimation of rivaroxaban concentrations <50 ng/mL. These results should be confirmed on a larger cohort of patients. Patients bridged with LMWH have inaccurate estimates of low levels of rivaroxaban and the 3 assays studied should not be used to estimate if it is safe to perform a procedure.
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Affiliation(s)
- Sarah Lessire
- 1 Department of Anesthesiology, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium.,2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- 2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Lionel Pochet
- 2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Anne-Sophie Dincq
- 1 Department of Anesthesiology, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Anne-Sophie Larock
- 3 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Maximilien Gourdin
- 1 Department of Anesthesiology, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- 2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Bernard Chatelain
- 4 Haematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - François Mullier
- 4 Haematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
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Albaladejo P, Bonhomme F, Blais N, Collet JP, Faraoni D, Fontana P, Godier A, Llau J, Longrois D, Marret E, Mismetti P, Rosencher N, Roullet S, Samama CM, Schved JF, Sié P, Steib A, Susen S. Management of direct oral anticoagulants in patients undergoing elective surgeries and invasive procedures: Updated guidelines from the French Working Group on Perioperative Hemostasis (GIHP) - September 2015. Anaesth Crit Care Pain Med 2016; 36:73-76. [PMID: 27659969 DOI: 10.1016/j.accpm.2016.09.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 09/09/2016] [Indexed: 11/16/2022]
Abstract
Since 2011, data on patients exposed to direct oral anticoagulants (DOAs) while undergoing invasive procedures have accumulated. At the same time, an increased hemorrhagic risk during perioperative bridging anticoagulation without thrombotic risk reduction has been demonstrated. This has led the GIHP to update their guidelines published in 2011. For scheduled procedures at low bleeding risk, it is suggested that patients interrupt DOAs the night before irrespective of type of drug and to resume therapy six hours or more after the end of the invasive procedure. For invasive procedures at high bleeding risk, it is suggested to interrupt rivaroxaban, apixaban and edoxaban three days before. Dabigatran should be interrupted according to the renal function, four days and five days if creatinine clearance is higher than 50mL/min and between 30 and 50mL/min, respectively. For invasive procedures at very high bleeding risk such as intracranial neurosurgery or neuraxial anesthesia, longer interruption times are suggested. Finally, bridging with parenteral anticoagulation and measurement of DOA concentrations can no longer routinely be used.
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Affiliation(s)
- Pierre Albaladejo
- Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble-Alpes, 38043 Grenoble, France.
| | - Fanny Bonhomme
- Division of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Normand Blais
- Department de Medicine - University of Montréal, CHUM - Hôpital Notre-Dame, Montréal, Quebec, Canada
| | - Jean-Philippe Collet
- Univ Paris 06 (UPMC), ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (APHP), Paris, France
| | - David Faraoni
- Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Pierre Fontana
- Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Anne Godier
- Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Juan Llau
- Department of Anesthesiology and Critical Care. Hospital Clínic Universitari, Valencia, Spain
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, University Paris Diderot, Sorbonne Paris Cité, U1148 INSERM, Paris, France
| | - Emmanuel Marret
- Department of Anesthesiology, American Hospital of Paris & Institut Hospitalier Franco-Britannique
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Nadia Rosencher
- Department of Anaesthesia and Intensive Care Medicine, Cochin and Hôtel-Dieu University Hospitals, Paris Descartes University, Paris, France
| | - Stéphanie Roullet
- Department of Anaesthesia and Intensive Care Medicine, Cochin and Hôtel-Dieu University Hospitals, Paris Descartes University, Paris, France
| | - Charles-Marc Samama
- Service d'Anesthésie Réanimation 1, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | | | - Pierre Sié
- Department of Hematology, Toulouse University Hospital, Toulouse, France
| | - Annick Steib
- Department of Anesthesiology and Intensive Care, University Hospital, Strasbourg, France
| | - Sophie Susen
- Department of Hematology and Transfusion, Lille University Hospital, Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
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[Direct oral anticoagulant associated bleeding]. JOURNAL DES MALADIES VASCULAIRES 2016; 41:272-8. [PMID: 27297642 DOI: 10.1016/j.jmv.2016.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/23/2016] [Indexed: 11/21/2022]
Abstract
Direct oral anticoagulants (DOAC) are recommended for stroke prevention in atrial fibrillation and for the treatment of venous thromboembolism. However, they are associated with hemorrhagic complications. Management of DOAC-induced bleeding remains challenging. Activated or non-activated prothrombin concentrates are proposed, although their efficacy to reverse DOAC is uncertain. Therapeutic options also include antidotes: idarucizumab, antidote for dabigatran, has been approved for use whereas andexanet alpha, antidote for anti-Xa agents, and aripazine, antidote for all DOAC, are under development. Other options include hemodialysis for the treatment of dabigatran-associated bleeding and administration of oral charcoal if recent DOAC ingestion. DOAC plasma concentration measurement is necessary to guide DOAC reversal. We propose an update on DOAC-associated bleeding, integrating the availability of dabigatran antidote and the critical place of DOAC concentration measurements.
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