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Cosmo Godino on DOAC Use in AF: Association With Acute Thromboembolic and Bleeding Events
Cosmo Godino/LinkedIn
Sep 21, 2025, 19:18

Cosmo Godino on DOAC Use in AF: Association With Acute Thromboembolic and Bleeding Events

Cosmo Godino, Interventional Cardiologist at Heart Valve Center, IRCCS San Raffaele Hospital, shared on LinkedIn:

”Is your blood thinner at the right level?
For years we’ve treated direct oral anticoagulants (DOACs) as “set and forget” drugs.

Routine monitoring wasn’t considered necessary. But the 4Levels Study challenges this assumption.

In 1 794 patients with atrial fibrillation presenting to the emergency department, we measured DOAC plasma levels at the exact moment they came in.

The findings are striking:

  • Low drug levels ≈ doubled risk of thrombosis: half of all thromboembolic events occurred in patients with DOAC levels in the lowest quartile, versus 26 % of controls.
  • High drug levels ≈ doubled risk of bleeding: 46 % of bleeding events occurred in patients with levels in the highest quartile, versus 23 % of controls.
  • These associations held across all four DOACs studied; odds of thrombosis or bleeding were about twice as high at the extremes.

This isn’t about trough or peak levels—it’s about drug levels at the moment patients are having strokes or spontaneous bleeds.

The controversial question: should we start monitoring DOAC levels in selected high‑risk patients? It’s too early to change practice, but the “one‑size‑fits‑all” approach may not be serving everyone.

Controlled trials are needed before any change in guidelines.

Proud to share this work with an incredible team.”

Read the full paper in JTH.

Article: Plasma levels measurement of the 4 direct oral anticoagulants in patients with atrial fibrillation at the time of acute thromboembolic and bleeding events

Authors: Cosmo Godino, Riccardo Mazza, Carlo Gaspardone, Alessia Minerva, Rachele Sena, Gianmarco Cozzani, Anna Salerno, Michela Cera, Massimo Slavich, Leila Anna De Lorenzo, Giulio Leo, Giulia Nemola, Annalisa Fattorini, Luciano Crippa, Patrizia Della Valle, Alberto Margonato, Armando D’Angelo

Cosmo Godino on DOAC Use in AF: Association With Acute Thromboembolic and Bleeding Events

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Alberto Margonato Alessia Minerva Anna Salerno Annalisa Fattorini Armando D’Angelo Carlo Gaspardone Cosmo Godino Gianmarco Cozzani Giulia Nemola Giulio Leo Health Hematology Hemostasis Hemostasis Today Leila Anna De Lorenzo Luciano Crippa Massimo Slavich Medicine Michela Cera Patrizia Della Valle Rachele Sena Riccardo Mazza thrombosis
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