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Review
. 2017 Mar 7;135(10):e604-e633.
doi: 10.1161/CIR.0000000000000477. Epub 2017 Feb 6.

Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association

Amish N Raval, Joaquin E Cigarroa, Mina K Chung, Larry J Diaz-Sandoval, Deborah Diercks, Jonathan P Piccini, Hee Soo Jung, Jeffrey B Washam, Babu G Welch, Allyson R Zazulia, Sean P Collins; American Heart Association Clinical Pharmacology Subcommittee of the Acute Cardiac Care and General Cardiology Committee of the Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young; and Council on Quality of Care and Outcomes Research
Review

Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association

Amish N Raval et al. Circulation. .

Erratum in

Abstract

Non-vitamin K oral anticoagulants (NOACs) are now widely used as alternatives to warfarin for stroke prevention in atrial fibrillation and management of venous thromboembolism. In clinical practice, there is still widespread uncertainty on how to manage patients on NOACs who bleed or who are at risk for bleeding. Clinical trial data related to NOAC reversal for bleeding and perioperative management are sparse, and recommendations are largely derived from expert opinion. Knowledge of time of last ingestion of the NOAC and renal function is critical to managing these patients given that laboratory measurement is challenging because of the lack of commercially available assays in the United States. Idarucizumab is available as an antidote to rapidly reverse the effects of dabigatran. At present, there is no specific antidote available in the United States for the oral factor Xa inhibitors. Prothrombin concentrate may be considered in life-threatening bleeding. Healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input.

Keywords: AHA Scientific Statements; acute care; anticoagulants; non–vitamin K antagonist; periprocedural.

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Figures

Figure 1
Figure 1. Clotting cascade and anticoagulants
VKA indicates vitamin K antagonist.
Figure 2
Figure 2. Example of a “Serious Bleeding on a NOAC” protocol
BUN indicates blood urea nitrogen; CBC, complete blood count; IU, international units; IV, intravenous; NOAC, non–vitamin K antagonist oral anticoagulants; PCC, prothrombin complex concentrate; PRBC, packed red blood cells; PTT, partial thromboplastin time; and TT, thrombin time.
Figure 3
Figure 3. Periprocedural management of patients on NOACs (non–vitamin K antagonist oral anticoagulants)
CrCl indicates creatinine clearance; ICD, implantable cardioverter-defibrillator; PT, prothrombin time; SVT, supraventricular tachycardia; TE, thromboembolic event; TIA, transient ischemic attack; and VTE, venous thromboembolism. *Bridging may be considered in patients with a history of systemic embolus in the last 6 weeks.
See this image and copyright information in PMC

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