Atrial fibrillation (AF) catheter ablation is performed in patients receiving direct oral anticoagulants (DOACs) with intra-procedural unfractionated heparin (UFH) administration to achieve activated clotting time (ACT) at 300 s, as for vitamin K antagonist (VKA). We determined whether ACT monitoring might be transposed from VKA to DOAC-treated patients. Blood was taken from 124 patients receiving uninterrupted dabigatran, rivaroxaban, apixaban, or VKA or being untreated. DOAC concentration or INR (VKA) were measured. ACT was determined at baseline, and after spiking with UFH doses equivalent to 1000, 2500, 5000 and 10000 IU in vivo. At baseline, anticoagulants prolonged ACT differently, ACT was longer with dabigatran and shorter with apixaban despite similar concentrations. ACT strongly correlated with INR and dabigatran concentration, but not with apixaban or rivaroxaban concentrations. Moreover, UFH effects on ACT prolongation depended on the anticoagulant: dose-response curves in samples with VKA and dabigatran were parallel whereas ACT prolongation in response to UFH was significantly smaller with rivaroxaban and especially apixaban. Therefore, UFH to achieve ACT at 300 s might be transposed from VKA to uninterrupted dabigatran-treated patients but not to patients receiving FXa-inhibitors, especially apixaban. Targeting 300 s might expose to UFH overdosing and bleeding, questioning the current anticoagulation strategy.

译文

心房颤动 (AF) 导管消融是在接受直接口服抗凝剂 (doac) 和程序内普通肝素 (UFH) 给药的患者中进行的,以达到300 s的活化凝血时间 (ACT),如维生素k拮抗剂 (VKA)。我们确定了ACT监测是否可以从VKA转移到DOAC治疗的患者。从124名接受不间断达比加群、利伐沙班、阿哌沙班或VKA或未经治疗的患者中抽取血液。测量DOAC浓度或INR (VKA)。在基线和加入相当于体内1000、2500、5000和10000 IU的UFH剂量后测定ACT。在基线时,抗凝剂的作用时间不同,尽管浓度相似,但达比加群的作用时间较长,而阿哌沙班的作用时间较短。ACT与INR和达比加群浓度密切相关,但与阿哌沙班或利伐沙班浓度无关。此外,UFH对ACT延长的影响取决于抗凝剂: VKA和达比加群样品的剂量反应曲线是平行的,而利伐沙班 (尤其是阿哌沙班) 对UFH的反应的ACT延长明显较小。因此,UFH在300 s时实现ACT可以从VKA转移到不间断的达比加群治疗的患者,但不能转移到接受FXa抑制剂,尤其是阿哌沙班的患者。靶向300可能暴露于UFH过量和出血,质疑当前的抗凝策略。

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