Direct Oral Anticoagulants (DOACs)

November 11, 2022

Review the article, “DOAC-prompted Bleeding Fatal in Some Patients, Despite Successful Reversal in Many,” in ACEPNow, and test your knowledge with the following quiz.

Every year, around 3% of patients on direct oral anticoagulants (DOACs) experience a major bleeding event, which may require hospitalization and the administration of reversal agents, e.g., idarucizumab to reverse dabigatran.

Researchers performed a meta-analysis of 60 studies in which patients experienced severe bleeding related to DOAC use. Of the patients, 82% were receiving DOACs for ischemic stroke prevention due to their atrial fibrillation. All were treated for their bleeds with prothrombin complex concentrates, idarucizumab, or andexanet.

Which of the following is NOT a true finding or important consideration to weigh when interpreting the study?

A) The overall percentage of patients who achieved effective bleeding hemostasis after receiving reversal agents was 78.5%; it was similar among the different reversal agents.

B) The overall risk of mortality from severe bleeding from a DOAC-related event was 17.7% in this analysis, with slightly higher rates in patients with intracranial bleeds.

C) Not achieving bleeding homeostasis was strongly associated with a more than three-fold increase in the risk of death. Approximately half of patients with severe DOAC-related bleeding suffered from long-term moderate to severe disability. Therefore, clinicians should consider additional reversal attempts or other treatment modalities for patients whose bleeding is still uncontrolled.

D) Bleeding-related morbidity and mortality among patients with atrial fibrillation on DOACs is greater than the morbidity and mortality from patients with atrial fibrillation who are undertreated in terms of ischemic stroke prevention.

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