Heubner Lars, Grottke Oliver, Vicent Oliver, Spieth Peter Markus, Beyer-Westendorf Jan
Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany.
Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen University, Aachen, Germany.
Thromb J. 2024 Oct 8;22(1):89. doi: 10.1186/s12959-024-00659-8.
Bleeding events in patients receiving direct oral anticoagulation (DOAC) can be life-threatening even at therapeutic DOAC plasma concentrations, as anticoagulation impairs hemostasis and should therefore be identified immediately after hospital admission. The anticoagulatory effects of DOAC are typically not measurable in standard coagulation tests, such as PT or aPTT. Specific calibrated anti-FXa-tests allow specific drug monitoring, but they are too time-consuming for critical bleeding events and are commonly not available for 24 h/7 days in routine care. However, recent advances in point-of-care (POC) viscoelastic testing (VET) have shown a promising approach for rapid and quantitative detection of DOAC plasma concentrations using the Russell viper venom factor V activator (RVV for FXa-inhibitors) test or the ecarin clotting time (thrombin inhibitors). In acute bleeding situations, direct FXa inhibitors can be reversed by specific antidote andexanet alfa or hemostasis can be improved by prothrombin complex factor concentrates (PCCs). After reversal, confirmation of reversal efficacy is often requested, but no routine assays are currently available. Thus, the emergency management of bleeding DOAC patients is usually "blinded" with regard to reversal efficacy. POC VET laboratory assays might therefore also be helpful for measuring DOAC effects after reversal. We present a case series demonstrating the usefulness of RVV-clotting time post-DOAC reversal with andexanet alfa.
接受直接口服抗凝剂（DOAC）治疗的患者，即使DOAC血浆浓度处于治疗水平，出血事件也可能危及生命，因为抗凝作用会损害止血功能，因此在入院后应立即识别。DOAC的抗凝作用通常在标准凝血试验（如PT或aPTT）中无法测量。特定的校准抗FXa试验可进行特定药物监测，但对于严重出血事件来说耗时过长，而且在常规护理中通常无法实现每周7天、每天24小时随时可用。然而，即时检验（POC）粘弹性检测（VET）的最新进展显示，使用罗素蝰蛇毒因子V激活剂（FXa抑制剂用RVV）试验或蛇静脉酶凝血时间（凝血酶抑制剂），对于快速定量检测DOAC血浆浓度是一种很有前景的方法。在急性出血情况下，直接FXa抑制剂可用特异性解毒剂andexanet alfa逆转，或通过凝血酶原复合因子浓缩物（PCC）改善止血。逆转后，通常需要确认逆转效果，但目前尚无常规检测方法。因此，出血性DOAC患者的紧急处理在逆转效果方面通常是“盲目”的。POC VET实验室检测因此可能也有助于测量逆转后的DOAC效果。我们展示了一个病例系列，证明了使用andexanet alfa逆转DOAC后RVV凝血时间的作用。
