Management of urgent invasive procedures in patients treated with direct oral anticoagulants: An observational registry analysis

Abstract

Background: Patients treated with direct oral anticoagulants (DOACs) may require urgent procedures. Managing these patients is challenging due to different bleeding risks and may include laboratory testing, procedural delays, or haemostatic/reversal agent administration.

Objective: We evaluated management strategies and outcomes of urgent, non-haemostatic invasive procedures in patients treated with DOACs.

Methods and results: In a descriptive cohort study, we prospectively evaluated 478 patients in the GIHP-NACO registry, from June 2013 to November 2015. Hospitalised patients receiving dabigatran (n = 160), rivaroxaban (n = 274), or apixaban (n = 44) requiring urgent, procedural interventions were evaluated, of which 384/478 (80 %) were surgical procedures. Orthopaedic surgery included 216/384 patients (56 %), while gastrointestinal surgery included 75/384 (20 %) patients. On admission, the median age was 79 (70-85), and creatinine clearance was <60 mL·min^-1 in 316/478 (66 %) patients. DOAC concentration was determined in 277 (58 %) patients and was 85 ng·mL^-1 (median; range 0-764), 61 ng·mL^-1 (3-541), and 81 ng·mL^-1 (26-354) for dabigatran, rivaroxaban, and apixaban, respectively. Procedures were delayed in 194/455 (43 %) of the cases. Excessive bleeding was observed in 62/478 (13 %) procedures, and haemostatic agents were administered in 76/478 (16 %) procedures. By day 30, major cerebral and cardiovascular events were observed in 38/478 (7.9 %) patients, and mortality was 28/478 (5.9 %).

Conclusions: In the GIHP-NACO registry, before specific antidotes were available, DOAC treated patients undergoing urgent invasive procedures were delayed in nearly half of the cases, and showed a low rate of excessive bleeding, suggesting that most urgent procedures can be performed safely without DOAC reversal.

Clinical trial registration: www.

Clinicaltrials: gov. Identifier: NCT02185027.

Keywords: Activated prothrombin complex concentrates; Anticoagulant; Apixaban; Bleeding; Dabigatran; Delay; Direct oral anticoagulant; Prothrombin complex concentrates; Rivaroxaban; Urgent procedure.