ACC Consensus on Management of Anticoagulant-Related Bleeding
- Tomaselli GF, Mahaffey KW, Cuker A, et al.
- 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2020;Jul 14:[Epub ahead of print].
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:
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- For patients taking factor Xa inhibitors, use of andexanet alpha is recommended for reversal. PCC can be used if andexanet alpha is not available.
- 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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