American College of Physicians: Internal Medicine — Doctors for Adults ®


ACP Hospitalist® Weekly

In the News for the Week of February 15, 2017


Perioperative care

Guidance released on acute care, periprocedural management of patients on NOACs

The American Heart Association recently released a scientific statement on management of patients taking non-vitamin K antagonist oral anticoagulants (NOACs) in acute care and periprocedural settings.

For most patients, routine NOAC monitoring is unnecessary, the statement said. However, measuring the effect of NOACs may be helpful for clinical management in some acute care and periprocedural situations. Appropriate clinical decision making can be based on the time that the last drug was taken plus a recent assessment of creatinine clearance, the statement said.

Hospitals should develop protocols for anticoagulation reversal that involve multidisciplinary representation, including emergency medicine, pharmacy, and nursing as well as other subspecialities, the statement suggested. All patients who develop life-threatening bleeding while on NOACs should be managed with basic resuscitation principles, according to the statement.

The statement noted that there are limited data on management of patients with NOAC overdose but said that it is vitally important in the acute period to gather information on type of NOAC, ingested dose, time of ingestion, concomitant renal or liver failure, and relevant co-ingestion of other medications. The statement said that NOACs increase bleeding risk in patients with acute kidney injury and suggested that clinicians switch to a different anticoagulant or perform close measurement in this population until more efficacy and safety data are available.

Use of NOACs in patients with acute ischemic stroke presents several challenges for clinicians, the statement said, such as measurement of anticoagulant activity during neurovascular emergencies, the role of thrombolysis and endovascular therapy, and the reinstitution of oral anticoagulation after acute ischemic stroke. The statement noted that appropriate treatment in this population should balance the anticoagulant effect of NOACs with the intracerebral hemorrhage risk seen with reperfusion strategies. Similarly, the statement said, risks of recurrent thromboembolic events and hemorrhagic transformation must be considered when deciding to restart oral anticoagulation.

Regarding periprocedural management of patients taking NOACs, the statement noted that according to current data, perioperative bleeding risk appears low in nonurgent surgery. For invasive procedures, the statement said, NOACs should be managed according to procedure type in order to decrease bleeding risk. The statement reviewed different strategies for several clinical scenarios, including cardiac catheterization and percutaneous coronary intervention, cardioversion of atrial fibrillation, catheter ablation of atrial fibrillation, electronic device implantation, cardiovascular and noncardiovascular surgery, and neuraxial anesthesia.

The full statement, which includes tables comparing NOACs and listing their drug interactions, was published by Circulation on Feb. 6 and is available free of charge online.

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