2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants
A Report of the American College of Cardiology Solution Set Oversight Committee
Gordon F. Tomaselli, Kenneth W. Mahaffey, Adam Cuker, Paul P. Dobesh, John U. Doherty, John W. Eikelboom, Roberta Florido, Ty J. Gluckman, William J. Hucker, Roxana Mehran, Steven R. Messé, Alexander C. Perino, Fatima Rodriguez, Ravindra Sarode, Deborah M. Siegal and Barbara S. Wiggins
4F-PCC = four-factor prothrombin complex concentrate; aPCC = activated prothrombin complex concentrate; DOAC = direct-acting oral anticoagulant; DTI = direct thrombin inhibitor; FXa = Factor Xa; h = hours; ICH = intracranial hemorrhage; INR = international normalized ratio; IV = intravenous; OAC = oral anticoagulant, including DOACs and VKAs; PCC = prothrombin complex concentrate; VKA = vitamin K antagonist.
∗Reversal/hemostatic agents include repletion strategies such as PCCs, plasma, vitamin K, and specific reversal agents for DOACs (e.g., idarucizumab for dabigatran; andexanet alfa for apixaban or rivaroxaban).
†When PCCs are used to reverse VKAs, vitamin K should also always be given (see Figure 2 for dosing guidance).
‡If bleeding persists after reversal and there is laboratory evidence of a persistent dabigatran effect, or if there is concern for a persistent anticoagulant effect before a second invasive procedure, a second dose of idarucizumab may be reasonable.
§Refer to prescribing information for maximum units.
II In patients taking ≤5 mg apixaban or ≤10 mg rivaroxaban, administer low dose andexanet alfa = initial IV bolus 400 mg at a target rate of 30 mg/min, followed by IV infusion 4 mg/min for up to 120 minutes.
¶In patients taking >5 mg apixaban or >10 mg rivaroxaban, administer high dose andexanet alfa = initial IV Bolus 800 mg at a target rate of 30 mg/min, followed by IV infusion 8 mg/min for up to 120 minutes.
#ANNEXA-4 full report excluded patients with DOAC levels <75 ng/ml because those patients were considered to have clinically insufficient levels for reversal agent. If drug effect/level can be assessed without compromising urgent clinical care decisions, then assessment should be performed before andexanet alfa is administered
## In patients taking betrixaban or edoxaban, administer high dose andexanet alfa = initial IV Bolus 800 mg at a target rate of 30 mg/min, followed by IV infusion 8 mg/min for up to 120 minutes.
1. Sarode R, Milling TJ Jr, Refaai MA, et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma controlled, phase IIIb study. Circulation 2013; 128:1234-43.