The following are key points to remember from this American College of Cardiology (ACC) Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants:

1. A major bleed is one that involves a critical site, leads to hemodynamic instability, leads to a ≥2 g/dl hemoglobin decline, or requires ≥2 units of red blood cell transfusion. When a major bleed occurs, temporarily stopping the anticoagulant and initiating measures to control the bleeding source are required.
2. Any bleed that requires hospitalization, surgical procedure, or transfusion likely requires interruption of the anticoagulant along with appropriate measures to control the source of bleeding.
3. When quantitative tests of anticoagulant effect (e.g., dilute thrombin time for dabigatran, anti-factor Xa for factor Xa inhibitors) are not available, a qualitative test can be used to exclude clinically relevant drug levels.
4. For patients with dabigatran, a normal thrombin time or activated partial thromboplastin time usually excludes clinically relevant levels if sensitive reagents are used. Anti-factor Xa levels (either general or drug-specific) can be used to exclude clinically relevant levels for factor Xa inhibitors.
5. For patients with major bleeding or bleeding that requires intervention, use of vitamin K should be used to help reverse vitamin K antagonist (VKA). Antiplatelet therapy can also be stopped.
6. Use of an anticoagulant “reversal” or hemostatic agent should be considered for life-threatening bleeding or major bleeding that does not resolve with initial management. Reversal agents should not be used for most patients with a nonmajor bleeding event.
7. For patients taking warfarin or other VKA, use of a four-factor prothrombin complex concentrate (4f-PCC) is advised for reversal. Fresh frozen plasma can be used if a 4f-PCC is not available.
8. For patients taking dabigatran, idarucizumab 5 g IV should be used for reversal. PCC or activated PCC can be used if idarucizumab is not available.
9. For patients taking factor Xa inhibitors, use of andexanet alpha is recommended for reversal. PCC can be used if andexanet alpha is not available.
10. Once bleeding is controlled, patients should be assessed for restarting their anticoagulant. If the patient is at low thromboembolic risk (e.g., atrial fibrillation with CHA₂DS₂-VASc score <2-3, provoked venous thromboembolism >3 months prior), then discontinuing anticoagulation is recommended. If bleeding occurred in a critical organ or the source has not been identified, then a delayed restart of anticoagulation is recommended. All other patients should likely restart their anticoagulation as soon as it is medically safe to do so.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Anticoagulation Management and Atrial Fibrillation, Anticoagulation Management and Venothromboembolism, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Erythrocyte Transfusion, Factor Xa Inhibitors, Geriatrics, Hemorrhage, Partial Thromboplastin Time, Platelet Aggregation Inhibitors, Secondary Prevention, Thrombin Time, Vascular Diseases, Venous Thromboembolism, Vitamin K, Warfarin

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