Management of direct oral anticoagulants in percutaneous coronary and structural interventions

The management of direct oral anticoagulants (DOAC) during percutaneous coronary interventions is a common challenge in clinical practice. The periprocedural management remains highly variable and insufficiently evidence based. This review summarizes the pharmacokinetic properties of DOACs, evaluates contemporary guideline recommendations, and examines observational and prospective evidence for interruption versus continuation strategies in coronary and structural interventions. For percutaneous coronary interventions, predominantly via radial-access, observational evidence suggests that uninterrupted DOAC therapy is associated with low rates of bleeding and thromboembolism, questioning the routine practice of pre-procedural interruption in low-risk cases. In contrast, patients undergoing transcatheter structural interventions are older, requiring femoral access, and have a higher baseline bleeding risk. In this setting, recent data do not support routine continuation of anticoagulation. We propose a patient- and procedure-specific approach to DOAC management that prioritizes access site, procedural complexity, and renal function over uniform interruption protocols. There is a need for targeted prospective randomized studies on periprocedural and immediate postprocedural management in these populations.