The American College of Cardiology (ACC) recently issued an expert consensus decision pathway for managing anticoagulation in patients with nonvalvular atrial fibrillation (AF) undergoing surgical or invasive procedures. The decision pathway was published in the Journal of the American College of Cardiology.1

Approximately 1 of 5 individuals has AF, and most are treated with antithrombotic therapy, which includes oral anticoagulants (OACs).2 Patients with AF who undergo invasive procedures may require temporary interruption of their OAC, but periprocedural management of OACs varies widely across specialties and institutions. Evidence-based protocols are not commonly used, and periprocedural OAC management often requires coordination among several clinicians.

The Periprocedural Management of Anticoagulation Writing Committee, led by John Doherty, MD, from Jefferson Medical College of Thomas Jefferson University in Philadelphia, Pennsylvania, devised a decision pathway to help guide periprocedural OAC management for patients with AF, based on a review of the available evidence.

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“The pathway covers 4 separate processes surrounding anticoagulant interruption: 1) whether to interrupt, 2) when to interrupt, 3) whether to bridge, and 4) how to restart,” Dr Doherty told Cardiology Advisor.

According to the decision pathway, OACs do not need to be interrupted for procedures with no clinically important or low bleed risk.1

In cases that require OAC interruption, the duration of interruption depends on baseline international normalized ratio for patients taking vitamin K agonists (VKA) and on renal function for patients taking novel oral anticoagulants.1

The decision pathway also offers guidance on when and how to use parenteral bridging, taking into account bleed risk and thrombotic risk, as measured by the CHA2DS2-VASc score. According to Dr Doherty, patients taking a VKA with high thrombotic risk may need bridging therapy, whereas patients with intermediate thrombotic risk often do not. Patients treated with novel anticoagulant agents typically do not require bridging therapy.1

How and when to restart OACs postprocedure should be based on procedure- and patient-specific bleed risk, as outlined by the decision pathway.

According to Dr Doherty, decision support based on the pathway will be available at the point of care with an associated mobile app, which will include specific procedure-related bleeding risk assessments for many commonly performed procedures.

“The pathway offers the opportunity to make care safer and more uniform in an area where there is great variability in clinical practice,” Dr Doherty said. However, he noted, “guidance is limited to elective procedures in patients with nonvalvular atrial fibrillation, although certain steps in the pathway may be applicable to more urgent procedures.”

Although the pathway provides a framework for decision making regarding periprocedural anticoagulation in patients with AF, more research is needed. “Areas that require further investigation include future clinical trials in higher thrombotic risk populations that will refine recommendations on whether to bridge, and further trials on various procedures that can be performed without interrupting warfarin or novel anticoagulant agents,” Dr Doherty said.

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  1. Doherty JU, Gluckman TJ, Hucker WJ, et al; on behalf of the Periprocedural Management of Anticoagulation Writing Committee. 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force [published online January 5, 2017]. J Am Coll Cardiol. doi: 10.1016/j.jacc.2016.11.024
  2. Lloyd-Jones DM, Wang TJ, Leip EP, et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004;110:1042-1046. doi: 10.1161/01.CIR.0000140263.20897.42