ACC Provides Guidance on How to Manage Bleeding in Patients Taking Oral Anticoagulants

A new expert consensus decision pathway from the American College of Cardiology (ACC) aims to ease the management of patients who bleed while taking oral anticoagulation for any indication.

The document, published online December 1, 2017, ahead of print in the Journal of the American College of Cardiology, is meant to complement a decision pathway focusing on periprocedural management of anticoagulation released earlier this year.

“With the proliferation of the use of oral anticoagulants, now with direct oral anticoagulants, I think general practitioners in particular but even subspecialists need some guidance about how to manage anticoagulation therapy around the time of procedures or around the time of spontaneous bleeding,” Gordon Tomaselli, MD (Johns Hopkins School of Medicine, Baltimore, MD), chair of the writing committee for the new guidance, told TCTMD.

‘Living Document’

The pathway, which applies to both vitamin K antagonists and non-vitamin K antagonist oral anticoagulants (NOACs), takes clinicians from the assessment of bleed severity to acute medical and surgical management, to use of reversal agents, and finally to consideration of the appropriateness and timing of reinitiating anticoagulation. Flow diagrams throughout the document are meant to ease decision-making.

For simplicity, bleeding severity was divided into major and nonmajor. Major bleeds are those associated with hemodynamic compromise, those in a critical anatomic site, those requiring a transfusion of two or more units of packed red blood cells, and those resulting in a hemoglobin drop of at least 2 g/dL. All other bleeds are considered nonmajor.

The other key part of the document, Tomaselli said, is the section discussing whether and when to restart anticoagulation after a bleed. That’s an area with a limited evidence base, which makes it perhaps the most controversial aspect of the document, he added.

The authors state that there is a net clinical benefit to reinitiating anticoagulation after a bleed in most cases, specifying, however, that the indication for therapy—as well as the balance of risks and benefits—should be reassessed before deciding whether to put patients back on treatment.

Tomaselli said the decision pathway is meant to be a “living document” that changes as new evidence becomes available because there are a number of areas where there remains uncertainty about what to do. One area where he anticipates changes is in the use of specific reversal agents, as there are multiple antidotes for the NOACs currently under development.

Taking a broader view, Tomaselli said these types of pathways are “designed in a way to overcome some of the deficiencies of the more recent guidelines, which tend to be ponderous, extensively lengthy, and make it difficult to cull out what the key features are.”

These practical decision pathways, on the other hand, deal with specific clinical problems. They’re driven by the literature like guidelines but are designed to be easy-to-use tools for managing problems faced by practitioners on a routine basis, Tomaselli said. These documents complement guidelines, which remain the most up-to-date reference sources for many of the recommendations found in the pathways, he added.