The American College of Cardiology (ACC) released a new expert consensus decision pathway intended to guide clinicians in the management of acute bleeding in patients treated with oral anticoagulants (OACs) and to supplement the 2017 ACC Expert Consensus Decision Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation (AF).

The pathway focused on bleeding management in patients taking direct OACs (DOACs) or vitamin K antagonists for any indication. The ACC writing committee also considered the role of antiplatelet agents in the treatment algorithms. Bleeding classification was categorized simply as major or nonmajor.

On developing the decision pathway, the writing committee established several general clinical assumptions: standard resuscitative measures should always be performed quickly in the setting of bleeding with hemodynamic compromise; the indications for anticoagulation therapy should include AF, venous thromboembolism, prosthetic cardiac valves, prior thromboembolism, intracardiac thrombus, and the presence of a mechanical cardiac support device (eg, left ventricular assist device); recommendations for restarting or withdrawing anticoagulant therapy refers to both DOACs and vitamin K antagonists; and that the healthcare provider will seek input from the appropriate specialists when necessary and include the patient and/or family in shared decision making when possible.

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In a summary graphic, the decision pathway first asks whether more than 1 of the following factors apply: bleeding at a critical site, hemodynamic instability, or clinically overt bleeding with hemoglobin decrease ≥2 g/dL or administration of ≥2 units of red blood cells. If the bleeding is considered major, then the provider should determine whether or not the bleeding is at a critical site or is life-threatening.

If the bleed is life-threatening, the pathway recommends stopping the OAC and initiating appropriate measures to control the bleeding, possibly by using a suggested reversal agent (depending on the specific OAC). If the bleed is not life-threatening, the pathway still recommends stopping the OAC and initiating appropriate measures to control the bleeding. If, after the patient is stable, there is no clinical indication for continuing the OAC, anticoagulation therapy may be stopped.

However, if there is still a clinical indication for the OAC, the pathway then asks if more than 1 of the following factors apply: bleed occurred at a critical site, the patient is at a high risk for another bleed or for death/disability with rebleeding, the bleeding source has not been identified, surgical or invasive procedures are planned, and/or the patient does not want to restart the OAC. If 1 or more of these factors applies, the pathway recommends delaying the restart of anticoagulation therapy. If not, the pathway recommends restarting anticoagulation.

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Conversely, if the bleed is considered nonmajor, then the provider must determine whether or not the bleed requires hospitalization, surgical or procedural intervention, or transfusion. If yes, then the OAC should be stopped and appropriate measures to control the bleeding should be initiated. If no, then the patient may continue the OAC and again, appropriate measures to control the bleeding should be initiated.

The decision pathway also includes recommendations for assessing bleed severity, reversal agent administration, and specific considerations for restarting or discontinuing anticoagulation.

The writing committee noted that their recommendations were based on quantitative evidence whenever possible, but that large knowledge gaps exist. “It is anticipated that as the population continues to age, more people will be treated with OACs. As more evidence is generated from ongoing research and clinical practice, further refinement to this decision pathway will be needed.”


Tomaselli GF, Mahaffey KW, Cuker A, et al; on behalf of the Task Force on Expert Consensus Decision Pathways. 2017 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulation. A report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways [published online December 1, 2017]. J Am Coll Cardiol. doi: 10.1016/j.jacc.2017.09.1085