ACC Issues Decision-Making Guide for Periprocedural Management of Anticoagulation in Nonvalvular Atrial Fibrillation

By Amy Orciari Herman

Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM

The American College of Cardiology has published an expert consensus decision pathway to help guide clinicians in managing periprocedural anticoagulation in patients with nonvalvular atrial fibrillation who are on long-term treatment with oral anticoagulants.

Among the key points, published in the Journal of the American College of Cardiology:

• When deciding whether to interrupt anticoagulation, clinicians should take into account the type of oral anticoagulant (e.g., vitamin K antagonist vs. direct oral anticoagulant), the patient's bleeding risk, and the procedure's bleeding risk.

• To assess the patient's bleeding risk, providers should use the HAS-BLED score (see link below) and also consider bleeding events within the past 3 months, platelet abnormalities, elevated INR measurements, and history of procedural bleeding.

• Vitamin K antagonist therapy should not be interrupted in patients at low risk for bleeding.

• When vitamin K antagonists must be interrupted, they should be stopped 3–4 days before the procedure for INR 1.5–1.9, 5 days before the procedure for INR 2.0–3.0, and at least 5 days before the procedure for INR greater than 3.0. Within 24 hours before the procedure, clinicians should recheck the INR.

• For patients on direct oral anticoagulants who require anticoagulation interruption, the estimated creatinine clearance and procedural bleeding risk should be used to determine the number of doses to skip.