Abstract Number: PB2056
Meeting: ISTH 2020 Congress
Background: EHRA guidelines recommend pre-operative DOAC therapy interruption based on pharmacokinetics, procedure-associated bleeding risk, and estimated creatinine clearance (ECrCl). In our Institution, 24h measurement of DOACs plasma levels is available.
Aims: Managing pre-operative interruption of DOACs based on trough plasma levels and estimated creatinine clearance.
Methods: From January 2014 to December 2019, 324 patients (86% with NVAF, 65.4% men, mean age 77±10 years, mean ECrCl 71±30 ml/min) on dabigatran etexilate (n=96, 29.6%), apixaban (n=100, 30.9%), rivaroxaban (n=97, 29.9%), and edoxaban (ED, n=31, 9.6%) underwent elective invasive maneuvers (n=44, 13.6%), minor (n=71, 21.9%) and, importantly, major surgery (n=209, 64.5%). DOACs trough levels (ng/ml), measured a median of 15 days before intervention, were 116±75, 123±73, 42±47, and 44±43, respectively. Seventy-two patients (22.2%, 18 on dabigatran etexilate) had ECrCl < 50 ml/min. Timing of last DOACs intake was decided based on trough levels and the expected half-life of the DOAC, aiming at levels ≤30 ng/ml on the morning of the intervention, when all patients had DOACs' levels measured. Hemoglobin loss was taken as a measure of bleeding.
Results: The average time of last DOAC intake before the morning of intervention was 38±21 hours. On the morning of the intervention, DOACs levels (ng/ml) were 13±13 (dabigatran),15±18 (apixaban), 6±9 (rivaroxaban), and 7±8 (edoxaban), with 90% of measurements ≤30 ng/ml. Levels exceeding 50 ng/ml were observed in 7 patients (2.2%), with peak levels (ng/ml) of 76 (dabigatran), 69 (apixaban), 39 (rivaroxaban), and 32 (edoxaban). There was no instance of unexpected bleeding.
Conclusions: Compared to EHRA guidelines, timing of interruption of DOACS based on trough measurements is safe and may avoid early interruptions, potentially dangerous in patients at high thromboembolic risk.
To cite this abstract in AMA style:Tomassini L, Della Valle P, Fattorini A, Pattarini E, Pozzi L, Crippa L, D'Angelo A. Management of DOACs in Elective Surgery Procedures: A Measurement Based Approach [abstract]. Res Pract Thromb Haemost. 2020; 4 (Suppl 1). https://abstracts.isth.org/abstract/management-of-doacs-in-elective-surgery-procedures-a-measurement-based-approach/. Accessed December 6, 2023.
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