Abstract Number: PB0081
Meeting: ISTH 2021 Congress
Theme: Coagulation and Natural Anticoagulants » Critical Care and Perioperative
Background: Management of bleeding and emergency invasive procedures remains challenging in patients on Direct Oral AntiCoagulants (DOACs). To manage these patients, the French working Group on Perioperative Hemostasis (GIHP) published guidelines1, based on DOAC level.
Aims: Evaluation of the management of bleeding and emergency invasive procedures in patients on DOAC according to the GIHP guidelines1; and identification of risk factors associated with poor outcomes, over a five-year period.
Methods: We retrospectively included all patients with a DOAC measurement admitted for the management of an emergency invasive procedure or bleeding in the University Hospital of Rennes between 2014 and 2018. Poor outcomes were bleeding (ISTH criteria) or thrombotic complications, and death.
Results: We included 595 patients with 1006 DOAC measurements, corresponding to 592 situations: 432 emergency invasive procedures and 160 bleedings.The characteristics of patients in the invasive procedure and bleeding situations are presented in table 1. Emergency procedures were mainly orthopedics (34%) and neurosurgery (12%). Bleeding were mainly critical (39%) or severe (29%), with 34% intracranial and 20% gastrointestinal. Adherence to the guidelines was 85%, of which 91% of urgent procedures and 67% of bleedings.
| Invasive procedures group n=432 |
Bleeding group n=160 |
p* | |
| Age (years) Mean ±SD |
76.19 ±12.56 | 73.94 ±12.91 | 0.0561 |
| Indication n (%) AF VTE Others/Unknown |
347 (80.3%) 55 (12.7%) 30 (6.9%) |
131 (81.9%) 20 (12.5%) 9 (5.6%) |
0.9056 |
| DOAC n (%) Apixaban Rivaroxaban Dabigatran |
205 (47.5%) 168 (38.9%) 59 (13.7%) |
65 (40.6%) 75 (46.9%) 20 (12.5%) |
0.2096 |
| Apixaban n (%) < 50 ng/mL [50-200[ ng/mL ≥ 200 ng/mL |
68 (33.2%) 108 (52.7%) 29 (14.1%) |
12 (18.5%) 44 (64.6%) 11 (16.9%) |
0.049 |
| Rivaroxaban n (%) < 50 ng/mL [50-200[ ng/mL ≥ 200 ng/mL |
101 (60.1%) 46 (27.4%) 21 (12.5%) |
19 (25.3%) 31 (41.3%) 25 (33.3%) |
<0.0001 |
| Dabigatran n (%) < 50 ng/mL [50-200[ ng/mL ≥ 200 ng/mL |
35 (59.3%) 21 (35.6%) 3 (5.1%) |
2 (10.0%) 8 (40.0%) 10 (50.0%) |
<0.0001 |
| Adherence to guidelines n (%) Yes No |
393 (91%) 39 (9%) |
107 (66.9%) 53 (33.1%) |
<0.0001 |
| Reversal n (%) Use of reversal agent DOAC discontinuation No reversal |
42 (9.7%) 365 (84.5%) 25 (5.8%) |
60 (37.5%) 75 (46.9%) 25 (15.6%) |
<0.0001 |
| Complication n (%) Yes / Death No |
41 (9.5%) 391 (90.5%) |
40 (25%) 120 (75%) |
<0.0001 |
General characteristics of the study patients. SD: standard deviation, AF: atrial fibrillation, VTE: venous thrombo-embolism, DOAC: direct oral anticoagulant * bleedings versus invasive procedures
Risk factors associated with poor outcomes are depicted in figure 1. On univariate logistic regression, adherence to GIHP propositions was significantly associated with less complications or death for the total emergency situations (OR=0.44; [0.26-0.77]). A concentration of rivaroxaban under 200 ng/mL was significantly associated with fewer poor outcomes in univariate (OR=0.43; [0.19-1.00], p=0.0493) and multivariate (OR=0.27; [0.13-0.58], p=0.0007) analysis.
Forest plot of factors associated with poor outcomes (bleeding or thrombotic complications and death) in the total population (urgent invasive procedures and bleeding). Odds ratio (OR), 95% confidence interval and p are presented for each factor. DOAC: Direct oral anticoagulant, GIHP: French working Group on Perioperative Hemostasis
Conclusions: Adherence to the GIHP propositions was associated with fewer complications or death in emergency situations. We although found an association between higher plasmatic levels of rivaroxaban and the occurrence of poor outcomes that has not been described so far, and may deserve further investigations.
1. Albaladejo P et al, Anaesthesia Critical Care & Pain Medicine. 2018;37(4):391-399.
To cite this abstract in AMA style:
Pontis A, Mansour A, Maurice A, Rousseau C, Nédelec-Gac F, Guéret P, Soulat L, Jégo P, Ecoffey C, Gouin-Thibault I. Management of Bleeding and Urgent Invasive Procedures in Patients Treated with Direct Oral Anticoagulants: An Observational Study over a Five-year Perio [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/management-of-bleeding-and-urgent-invasive-procedures-in-patients-treated-with-direct-oral-anticoagulants-an-observational-study-over-a-five-year-perio/. Accessed June 25, 2022.« Back to ISTH 2021 Congress
ISTH Congress Abstracts - https://abstracts.isth.org/abstract/management-of-bleeding-and-urgent-invasive-procedures-in-patients-treated-with-direct-oral-anticoagulants-an-observational-study-over-a-five-year-perio/