The American College of Cardiology (ACC) has released an expert consensus decision pathway on management of bleeding in patients on oral anticoagulants.It has been published in Journal of the American College of Cardiology. The guideline includes decision pathways on how to assess severity and define bleeding, whether major or minor and how to manage them.
Key Points :
- Use of direct oral anticoagulants (DOACs) is common for conditions such as atrial fibrillation and venous thromboembolism. Their use will continue to increase in the future.
- Bleeding is a known complication of all OACs, including DOACs. However, evaluation and management of bleeding can be challenging, especially for patients taking chronic DOAC medications due to a lack of readily available blood tests.
- A key first step is to assess the severity of bleeding by asking: (1) is there bleeding at a critical site?; (2) is the patient hemodynamically unstable?; and (3) is there clinically overt bleeding with a hemoglobin drop of ≥2 g/dl or the need for 2+ units of red blood cell transfusion?
- Unless the bleed is considered nonmajor (no to all three questions above) and the bleeding does not require hospitalization or surgical/procedural intervention, the DOAC medication should be stopped.
- To assess if any clinically relevant drug level is present, patients taking dabigatran should undergo a dilute thrombin test, ecarin clotting test, or ecarin chromogenic assay. A normal activated partial thromboplastin time (aPTT) might exclude clinically relevant levels of dabigatran if a sensitive reagent is used.
- To assess if any clinically relevant drug level is present, patients taking factor Xa inhibitors (e.g., apixaban, edoxaban, and rivaroxaban) should undergo chromogenic anti-Xa activity assay testing. A normal PT and aPTT is not useful for excluding clinically relevant drug levels for patients using factor Xa inhibitors.
- Use of a reversal agent should be reserved only for patients with a life-threatening bleed or a major bleed in a critical site.
- To reverse vitamin K antagonists (e.g., warfarin), use of 5-10 mg intravenous vitamin K is appropriate for major bleeding events, while 2-5 mg of oral or intravenous vitamin K can be used for nonmajor bleeding events that require hospitalization.
- Use of 4 factor prothrombin complex concentrate (PCC) is recommended for major bleeding in patients taking vitamin K antagonists or factor Xa inhibitors. For factor Xa inhibitors, a fixed dose of 50 units/kg is recommended.
- Patients with major bleeding while taking dabigatran should be administered idarucizumab 5 g IV or 4 factor PCC, if idarucizumab is not available.
- After the bleeding has been controlled, a shared decision making discussion is needed to determine if and when the DOAC medication should be restarted. A delayed restart is recommended when the bleed occurred in a critical site, the patient has a high risk of rebleeding or of death from a rebleed, the source of the bleed cannot be identified, or future surgical interventions are planned.
- For patients with gastrointestinal bleeds, restarting an OAC after 7+ days has been associated with better outcomes, including improved survival and reduced thromboembolism risk.
- For patients with intracranial hemorrhage, restarting oral antithrombotic agents should usually be delayed approximately 4 weeks.
This document was approved by the American College of Cardiology Clinical Policy Approval Committee in October 2017.
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Dr. Kamal Kant Kohli
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