Management of chronically anticoagulated patients
Anticoagulant therapies are widely used for the prevention of thrombotic events but are associated with the potential risk of bleeding as in the case of vitamin K antagonists including warfarin. The nonvitamin K oral anticoagulants (NOACs) are target specific as factor IIa (thrombin) or Xa inhibitors and are increasingly used in clinical practice. While interruption of anticoagulant therapy is appropriate for patients scheduled for elective surgery or those presenting with minor bleeding, patients with acute major bleeding or requiring urgent surgery and procedural interventions need rapid anticoagulation reversal. Current guidelines recommend the use of specific reversal agents including idarucizumab for dabigatran, and andexanet alfa for factor Xa inhibitors. However, andexanet alfa has not been studied in surgical or procedural patients and specific antidotes may not be available. As a result, most guidelines recommend other hemostatic agents including prothrombin complex concentrates for NOAC reversal in patients with life-threatening bleeding when a specific antidote is not available, and several case series have been reported using this approach. Similarly, antiplatelet agents are key to the management of patients with ischemic cardiovascular disease and/or atherosclerotic vascular disease, but they too pose a risk of bleeding. Some hemostatic therapies, such as rFVIIa, may have off-label potential for the reversal of P2Y12 receptor inhibitors; however, data supporting this approach are limited. Ultimately, adequately powered studies are required to fully validate reversal strategies for NOACs and antiplatelet agents.