The ACC on July 14 released the 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants in the Journal of the American College of Cardiology. The document focuses on acute bleeding management in patients being treated with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) for any indication.

Led by Writing Committee Chair Gordon F. Tomaselli, MD, FACC, and Vice Chair Kenneth W. Mahaffey, MD, FACC, the document updates parts of the 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. The new document builds on the 2017 expert consensus document by providing guidance for new OACs used in the prevention of venous thromboembolism (VTE) and new reversal strategies for factor Xa (FXa) inhibitors.

Specifically, the new pathway provides 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.

"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 nonmajor 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 hemostasis 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.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Dyslipidemia, Pulmonary Hypertension and Venous Thromboembolism, Anticoagulation Management and Atrial Fibrillation, Anticoagulation Management and Venothromboembolism, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Novel Agents

Keywords: Anticoagulants, Factor Xa Inhibitors, Platelet Aggregation Inhibitors, Venous Thromboembolism, Atrial Fibrillation, Factor Xa, Blood Platelets, Caregivers, Decision Making, Hemorrhage, Blood Coagulation, Risk Assessment

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