The American College of Cardiology has published an expert consensus decision pathway (ECDP) on the management of bleeding in patients being treated with direct oral anticoagulants (OACs) and vitamin K antagonists for any indication.
Published in the Journal of the American College of Cardiology (JACC), the document is a supplement to the 2017 ACC expert consensus decision pathway for peri-procedural management of anticoagulation in patients with nonvalvular atrial fibrillation, which addresses the management of patients undergoing planned surgical or interventional procedures. Its development was led by Writing Committee chair Gordon F Tomaselli (Albert Einstein College of Medicine, New York, USA), and vice chair Kenneth W Mahaffey (Stanford University Medical Center, Stanford, USA).
According to the ACC, the update to the 2017 pathway was created due to the emergence of new OACs for use in the prevention of venous thromboembolism and the introduction of new reversal strategies for factor Xa (FXa) inhibitors.
The recommendations include guidance for temporary or permanent interruption of therapy, general approaches to bleeding management, decision support for treatment with a reversal agent, and indications and timing for reinstituting anticoagulant treatment. The paper describes anticoagulation as the “cornerstone” of treatment for thromboembolic complications, and notes that secular trends in anticoagulation use have demonstrated a “relatively rapid adoption of direct acting oral anticoagulants for the most common indications for anticoagulation.”
“Irrespective of severity, local measures should be employed where possible to control any bleeding,” Tomaselli and Mahaffey write. For major bleeding management, the writing committee does not recommend routine administration of platelets for patients on antiplatelet agents, although this can be considered in specific cases, particularly when other measures, such as OAC reversal, have failed.
For non-major bleeding, the committee does not recommend routine OAC reversal but notes that it may be advisable to temporarily discontinue OAC treatment until the patient is clinically stable and haemostasis is achieved.
When there is an ongoing indication for OAC, the clinician should undertake a risk-benefit assessment that involves other practitioners, such as surgeons, interventionalists and neurologists, the document notes. In addition, the decision to restart anticoagulation therapy should involve shared decision-making with patients and caregivers.
Tomaselli and Mahaffey note “large gaps in knowledge” regarding treatment of patients who experience bleeding complications during OAC therapy. “It is anticipated that as the population continues to age, more people will be treated with OACs,” they write. Going forward, the expert consensus document will need “further refinement” as research and clinical practice lead to additional data, they conclude.