Direct oral anticoagulants or vitamin K antagonists in emergencies: comparison of management in an observational study

Ross I Baker^{1

2

3}, Grace Gilmore^{1

2}, Vivien Chen⁴, Laura Young⁵, Eileen Merriman⁶, Jennifer Curnow⁷, Joanne Joseph⁸, Jim Y Tiao^{1

2}, Jun Chih⁹, Simon McRae^{2

3}, Paul Harper¹⁰, Chee W Tan¹¹, Timothy Brighton¹², Gordon Royle¹³, Amanda Hugman¹⁴, Graeme J Hankey¹⁵, Helen Crowther¹⁶, Jirping Boey¹⁷, Alexander Gallus¹⁷, Philip Campbell¹⁸, Huyen Tran¹⁹; Thrombosis and Haemostasis Society of Australia and New Zealand Anticoagulation Reversal and Events Study Collaborative

Collaborators, Affiliations

Collaborators

Thrombosis and Haemostasis Society of Australia and New Zealand Anticoagulation Reversal and Events Study Collaborative:
V Chen, L Young, E Merriman, J Curnow, A Gallus, J Boey, Chee Wee Tan, S McRae, A Hugman, J Joseph, P Harper, T Brighton, G Royle, H Crowther, H Tran, P Campbell, R Baker

Affiliations

¹ Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia.
² Perth Blood Institute, Perth, Australia.
³ Hollywood Hospital Haemophilia Centre, Perth, Australia.
⁴ Concord Repatriation General Hospital, Concord Clinical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia.
⁵ Auckland City Hospital, Grafton, Auckland, New Zealand.
⁶ North Shore Hospital, Auckland, New Zealand.
⁷ Westmead Hospital, Sydney, Australia.
⁸ St Vincent's Hospital and School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales Sydney, Sydney, Australia.
⁹ Curtin School of Population Health, Perth, Australia.
¹⁰ Palmerston North Hospital, Palmerston North, New Zealand.
¹¹ Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia.
¹² Prince of Wales Hospital, Sydney, Australia.
¹³ Middlemore Hospital, Auckland, New Zealand.
¹⁴ St George Hospital, Sydney, Australia.
¹⁵ Perron Institute for Neurological and Translational Science and The University of Western Australia, Perth, Australia.
¹⁶ Blacktown Hospital, Sydney, Australia.
¹⁷ Flinders Medical Centre, Flinders University, Adelaide, Australia.
¹⁸ University Hospital, Geelong, Australia.
¹⁹ Alfred Hospital, Melbourne, Australia.

PMID: 37601024
PMCID: PMC10439397
DOI: 10.1016/j.rpth.2023.100196

Direct oral anticoagulants or vitamin K antagonists in emergencies: comparison of management in an observational study

Ross I Baker et al. Res Pract Thromb Haemost. 2023.

. 2023 May 26;7(5):100196.

doi: 10.1016/j.rpth.2023.100196. eCollection 2023 Jul.

Authors

Collaborators

Thrombosis and Haemostasis Society of Australia and New Zealand Anticoagulation Reversal and Events Study Collaborative:
V Chen, L Young, E Merriman, J Curnow, A Gallus, J Boey, Chee Wee Tan, S McRae, A Hugman, J Joseph, P Harper, T Brighton, G Royle, H Crowther, H Tran, P Campbell, R Baker

Affiliations

¹ Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia.
² Perth Blood Institute, Perth, Australia.
³ Hollywood Hospital Haemophilia Centre, Perth, Australia.
⁴ Concord Repatriation General Hospital, Concord Clinical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia.
⁵ Auckland City Hospital, Grafton, Auckland, New Zealand.
⁶ North Shore Hospital, Auckland, New Zealand.
⁷ Westmead Hospital, Sydney, Australia.
⁸ St Vincent's Hospital and School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales Sydney, Sydney, Australia.
⁹ Curtin School of Population Health, Perth, Australia.
¹⁰ Palmerston North Hospital, Palmerston North, New Zealand.
¹¹ Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia.
¹² Prince of Wales Hospital, Sydney, Australia.
¹³ Middlemore Hospital, Auckland, New Zealand.
¹⁴ St George Hospital, Sydney, Australia.
¹⁵ Perron Institute for Neurological and Translational Science and The University of Western Australia, Perth, Australia.
¹⁶ Blacktown Hospital, Sydney, Australia.
¹⁷ Flinders Medical Centre, Flinders University, Adelaide, Australia.
¹⁸ University Hospital, Geelong, Australia.
¹⁹ Alfred Hospital, Melbourne, Australia.

PMID: 37601024
PMCID: PMC10439397
DOI: 10.1016/j.rpth.2023.100196

Abstract

Background: Restoring hemostasis in patients on oral anticoagulants presenting with major hemorrhage (MH) or before surgical intervention has changed, with the replacement of vitamin K antagonist (VKA) with direct oral anticoagulants (DOACs).

Objectives: To observe the difference in urgent hemostatic management between patients on VKA and those on DOACs.

Methods: A multicenter observational study evaluated the variation in laboratory testing, hemostatic management, mortality, and hospital length of stay (LOS) in patients on VKA or DOACs presenting with MH or urgent hemostatic restoration.

Results: Of the 1194 patients analyzed, 783 had MH (61% VKA) and 411 required urgent hemostatic restoration before surgery (56% VKA). Compared to the international normalized ratio (97.6%), plasma DOAC levels were measured less frequently (<45%), and the time taken from admission for the coagulation sample to reach the laboratory varied widely (median, 52.3 minutes; IQR, 24.8-206.7). No significant plasma DOAC level (<50 ng/mL) was found in up to 19% of patients. There was a poor relationship between plasma DOAC level and the usage of a hemostatic agent. When compared with patients receiving VKA (96.5%) or dabigatran (93.7%), fewer patients prescribed a factor Xa inhibitor (75.5%) received a prohemostatic reversal agent. The overall 30-day mortality for MH (mean: 17.8%) and length of stay (LOS) (median: 8.7 days) was similar between VKA and DOAC patients.

Conclusion: In DOAC patients, when compared to those receiving VKA, plasma DOAC levels were measured less frequently than the international normalized ratio and had a poor relationship with administering a hemostatic reversal agent. In addition, following MH, mortality and LOS were similar between VKA and DOAC patients.

Keywords: anticoagulants; coagulation; dabigatran; hemorrhage; hemostatics.

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Figures

**Figure 1**
Anticoagulation Reversal and Events Study (ARES) Collaborative recruitment strengthening the reporting of observational studies in epidemiology (STROBE) diagram. DOAC, direct oral anticoagulant; MH, major hemorrhage; UHR, urgent hemostatic restoration; VKA, vitamin K antagonist.

**Figure 2**
Patients with major hemorrhage or urgent hemostatic restoration who had a dabigatran drug level and were administered idarucizumab. There were a total of 79 patients with insert (n = 34). The median dabigatran level is 200 ng/mL (solid line; IQR, 64-390 ng/mL). A dashed line at 50 ng/mL represents a level where if over, hemostatic agents or an oral anticoagulant antidote is recommended. Red triangles, idarucizumab administered; grey circles, no idarucizumab administered.

**Figure 3**
Patients with major hemorrhage or urgent hemostatic restoration who had a factor Xa (FXa) inhibitor (rivaroxaban and apixaban) drug level and were administered prothrombin complex concentrate (PCC). There were a total of 83 patients. The overall median anti-FXa level is 132 ng/mL, represented by the solid line (IQR, 73-280/mL). Dashed line at 50 ng/mL represents a level where if over, hemostatic agents or an oral anticoagulant antidote is recommended. Red triangles, PCC administered; grey circles, no PCC administered.

**Figure 4**
Thirty-day mortality for patients with major hemorrhage. All oral anticoagulants (n = 139; 17.8%), warfarin (vitamin K antagonist, n = 81; 17.0%), dabigatran (n = 35; 22.2%), rivaroxaban (n = 10, 15.4%), and apixaban (n = 13, 15.5%).

See this image and copyright information in PMC

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Direct oral anticoagulants or vitamin K antagonists in emergencies: comparison of management in an observational study

Collaborators

Affiliations

Direct oral anticoagulants or vitamin K antagonists in emergencies: comparison of management in an observational study

Authors

Collaborators

Affiliations

Abstract

Figures

References

LinkOut - more resources

Full Text Sources