Clinical

Decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation

Clinical question: This work group synthesized available data to address whether and when anticoagulant therapy should be interrupted, whether and how anticoagulant bridging with a parenteral agent should be performed, and when and how anticoagulant therapy should be restarted for those who require temporary interruption.

Background: Atrial fibrillation is the most common sustained arrhythmia worldwide. Antithrombotic therapy, with a strong preference to oral anticoagulant (vitamin K antagonists [VKA] or Direct oral anticoagulant [DOAC]) over antiplatelet, is recommended for patients with high thrombotic risk. Temporary interruption is frequently necessary to mitigate bleed risk with surgical or invasive procedures. Although several factors go into the decision to interrupt anticoagulation, practice varies widely.

Study design: Data review and commentary.

Setting: Veterans’ Affairs Hospitals.

Synopsis: For the assessment of procedural bleed risk, the guideline provides bleeding risks levels: 1) no clinically important bleed risk, 2) low procedural bleed risk, 3) uncertain procedural bleed risk, or 4) intermediate/high procedural bleed risk.

For the assessment of patient-related bleed risk, consider the HAS-BLED (Hypertension, Abnormal Renal and Liver Function, Stroke–Bleeding, Labile INRs, Elderly, Drugs or Alcohol) score: bleeding in the preceding 3 months, bleeding with a similar procedure or prior bridging, abnormalities of platelet function, concomitant use of antiplatelet therapy, and/or supratherapeutic international normalized ratio.

Vitamin K Antagonists:

  • Do not interrupt for no clinically important or low bleed risk AND absence of patient-related bleed risk factor(s).
  • Interrupt for procedures with intermediate or high bleed risk OR procedures with uncertain bleed risk and the presence of patient-related bleed risk factor(s).
  • Consider interruption for procedure with no clinically important or low bleed risk AND the presence of patient-related bleed risk factor(s) OR procedures with uncertain bleed risk AND the absence of patient-related bleed risk factor(s).

Direct Oral Anticoagulants:

Can interrupt therapy for all bleed risks; duration based on creatinine clearance.

A procedure performed at the trough level may allow reinitiation the evening of or the day after the procedure with 1 or fewer dose(s) missed.

Bottom line: VKAs should be held based on surgical and patient bleed risk factors. Guidelines provide tools to calculate and consider. DOACs can always be held, preferably at trough times to minimize interruptions and for durations based on creatinine clearance.

Citation: Doherty JU, Gluckman TJ, Hucker WJ, et al. “2017 ACC Expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation.” J Am Coll Cardiol. 2017 Feb 21;69(7):871-98.

Dr. White is an instructor in the Division of Hospital Medicine, Loyola University Chicago.

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