Peri-procedural management of dabigatran and rivaroxaban: Duration of anticoagulant discontinuation and drug concentrations

•We measure per-procedural residual concentration of direct oral anticoagulant [DOAC]•Duration of DOAC discontinuation is the only factor associated with minimal [DOAC]•A 48-hour discontinuation does not guarantee a [DOAC] < 30 ng/mL in all patients•Normal PT and aPTT are flawed to predict [DOAC] < 30 ng/mL•DOAC should be stopped > 48 hr before procedures requiring normal coagulation

BackgroundPeri-procedural management of direct oral anticoagulants (DOAC) is challenging. The optimal duration of pre-procedural discontinuation that guarantees a minimal DOAC concentration ([DOAC]) at surgery is unknown. The usual 48-hour discontinuation might not be sufficient for all patients.ObjectivesTo test the hypothesis that a 48-hour DOAC discontinuation is not sufficient to ensure a minimal per-procedural [DOAC], defined as [DOAC] < 30 ng/mL. To investigate the factors associated with per-procedural [DOAC]. To evaluate the ability of normal PT and aPTT to predict [DOAC] < 30 ng/mL.MethodsPatients treated with dabigatran or rivaroxaban, and requiring any invasive procedure were included in this multicentre, prospective, observational study. [DOAC], PT and aPTT were measured during invasive procedure.ResultsSixty-five patients were enrolled. Duration of DOAC discontinuation ranged from 1-168 h. Per-procedural [DOAC] ranged from < 30 to 466 ng/mL. [DOAC] < 30 ng/mL occurred more frequently after 48-hour discontinuation than after a shorter delay. [DOAC] remained ≥ 30 ng/mL in 36% and 14% of measurements performed 24-48 h and 48 h-120 h after discontinuation, respectively. According to ROC curve, a cut-off value of 120 hours for DOAC discontinuation had a better specificity than a cut-off value of 48 hours to predict [DOAC] < 30 ng/mL. Normal PT and aPTT ratios had good specificity and positive predictive value, but limited sensitivity (74%) and negative predictive value (73%) to predict [DOAC] < 30 ng/mL.ConclusionsA 48-hour discontinuation does not guarantee a [DOAC] < 30 ng/mL in all patients. Normal PT and aPTT are flawed to predict this threshold and could not replace specific assays. Further studies are needed to define the relationship between per-procedural [DOAC] and clinical outcomes.