Advancing Point-of-Care Analysis: The Future of Thromboelastographic DOAC-Detection: A Systematic Review

Abstract Direct oral anticoagulants (DOACs) have largely replaced vitamin K antagonists owing to their predictable pharmacokinetics and improved safety. In emergency situations such as urgent surgery, major bleeding, or thrombolysis for acute ischemic stroke, rapid assessment of clinically relevant DOAC activity is essential. Conventional viscoelastic testing (VET) using devices such as ROTEM, TEG 5000, TEG6s, or ClotPro is insufficiently sensitive to detect DOACs, prompting the development of modified assays with specific activators. This systematic review summarizes recent advances in VET-based DOAC detection and evaluates the diagnostic performance of novel assay strategies and their correlation with plasma drug concentrations. A systematic search of PubMed and Google Scholar (January 2019–June 2025) was conducted in accordance with PRISMA 2020 recommendations. Twelve of 113 identified studies met the inclusion criteria. Ecarin-based assays demonstrated 100% sensitivity and specificity for detecting the direct thrombin inhibitor dabigatran. For direct factor Xa inhibitors—rivaroxaban, apixaban, and edoxaban—modified assays using Russell's Viper Venom, factor Xa-based reagents, and low-tissue-factor activation showed variable but generally good correlations with drug levels (r = 0.571–0.969). Sensitivity was lower for apixaban (83–97%) than for rivaroxaban (90–100%) and edoxaban (100%). Factor Xa-based and low-tissue-factor assays achieved sensitivities of 85 to 100% and specificities of 62 to 100%. In summary, modified VET assays show promise as rapid point-of-care tools for DOAC detection in emergency settings. Ecarin-based tests appear reliable for dabigatran, while Russell's Viper Venom and low-tissue-factor approaches may enable detection of direct factor Xa inhibitors. However, further clinical validation and standardization are required before routine implementation.