ACC Decision Pathway for Periprocedural Anticoagulation

Doherty JU, Gluckman TJ, Hucker WJ, et al.
2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol 2017;Jan 9:[Epub ahead of print].

The following are key points to remember about the American College of Cardiology Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation:

  1. These decision pathways were formed to assist clinicians with quickly and effectively making decisions regarding periprocedural management of anticoagulation for patients with nonvalvular atrial fibrillation who are treated with chronic oral anticoagulants.
  2. When considering if interrupting anticoagulation is necessary, clinicians should consider the type of oral anticoagulant (vitamin K antagonists [VKAs] with a long half-life vs. direct oral anticoagulants [DOACs] with a shorter half-life), the patient’s bleeding risk, the procedural bleeding risk, and any additional clinical information.
  3. Some procedures (e.g., implantation of pacemakers or implantable cardioverter-defibrillators) have demonstrated lower bleeding risks when VKA therapy is continued uninterrupted rather than interrupted and heparin bridging is administered.
  4. To assess a patient’s risk of bleeding, elements of the HAS-BLED score (hypertension, abnormal liver or renal function, prior stroke, prior major bleeding or anemia, labile international normalized ratio [INR] for VKA patients, age >65 years, concomitant use of antiplatelet agents or nonsteroidal anti-inflammatory drugs) should be assessed along with any recent bleeding events (within 3 months), platelet abnormalities, elevated INR values for VKA patients, and any prior procedural bleeding history.
  5. Do not interrupt VKA therapy in patients undergoing procedures with no clinically important risk or low risk of bleeding AND no patient-related factors that increase bleeding risk.
  6. When interrupting VKA therapy, the VKA should be stopped 3-4 days prior to procedure (for INR 1.5-1.9), 5 days prior to procedure (for INR 2.0-3.0), or at least 5 days prior to procedure (for INR >3.0). The INR should be re-checked within 24 hours before the procedure.
  7. Use of bridging parenteral heparin should only be considered in the following two scenarios: (1) VKA-treated patients at high risk of stroke or systemic embolism (>10% per year), including those with a CHA2DS2-VASc score of 7-9 or a recent (within 3 months) ischemic stroke, or (2) VKA-treated patients with a prior stroke or systemic embolism (≥3 months previously) who are not at a significant periprocedural bleeding risk.
  8. For patients on DOAC therapy who require interruption of anticoagulation therapy preprocedurally, the number of doses to be held is determined by the estimated creatinine clearance and the procedural bleeding risk. A standard table should be referenced for this decision-making process. Parenteral heparin bridging is not indicated for DOAC-treated patients.
  9. Before restarting oral anticoagulant therapy, ensure complete hemostasis. Otherwise, VKA therapy can usually be restarted within 24 hours and parenteral heparin bridging (if indicated) within 24-72 hours depending on post-procedural bleeding risk. DOAC therapy should not be reinitiated before 24-72 hours post-procedure without any parenteral heparin bridging based on post-procedure bleeding risk unless the patient cannot tolerate oral therapy.
  10. DOAC therapy should not be used in patients undergoing mechanical valve replacement.

Keywords: Anticoagulants, Arrhythmias, Cardiac, Anemia, Atrial Fibrillation, Blood Platelets, Cardiac Surgical Procedures, Creatinine, Defibrillators, Implantable, Embolism, Heart Valve Diseases, Hemorrhage, Hemostasis, Heparin, Hypertension, Platelet Aggregation Inhibitors, Primary Prevention, Secondary Prevention, Stroke, Vitamin K

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