PCC can be used if andexanet alpha is not available. For patients taking factor Xa inhibitors, use of andexanet alpha is recommended for reversal.PCC or activated PCC can be used if idarucizumab is not available.
Use of an anticoagulant “reversal” or hemostatic agent should be considered for life-threatening bleeding or major bleeding that does not resolve with initial management. Antiplatelet therapy can also be stopped. Anti-factor Xa levels (either general or drug-specific) can be used to exclude clinically relevant levels for factor Xa inhibitors.įor patients with major bleeding or bleeding that requires intervention, use of vitamin K should be used to help reverse vitamin K antagonist (VKA). When quantitative tests of anticoagulant effect (e.g., dilute thrombin time for dabigatran, anti-factor Xa for factor Xa inhibitors) are not available, a qualitative test can be used to exclude clinically relevant drug levels.įor patients with dabigatran, a normal thrombin time or activated partial thromboplastin time usually excludes clinically relevant levels if sensitive reagents are used.Any bleed that requires hospitalization, surgical procedure, or transfusion likely requires interruption of the anticoagulant along with appropriate measures to control the source of bleeding.When a major bleed occurs, temporarily stopping the anticoagulant and initiating measures to control the bleeding source are required.
A major bleed is one that involves a critical site, leads to hemodynamic instability, leads to a ≥2 g/dl hemoglobin decline, or requires ≥2 units of red blood cell transfusion.The following are key points to remember from this American College of Cardiology (ACC) Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants:
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