Updated Guidelines for Atrial Fibrillation

A task force from the American College of Cardiology (ACC) recently published an Expert Consensus Decision Pathway to provide guidance for the periprocedural management of anticoagulation in individuals with nonvalvular atrial fibrillation.

Some specific recommendations featured in the Decision Pathway include those related to the appropriate timing of interrupting anticoagulation, anticoagulant bridging with a parenteral agent periprocedurally, and restarting anticoagulant therapy for patients who require temporary interruption. 

The report defines bridging as “The process whereby an OAC [oral anticoagulant] is discontinued and replaced by a subcutaneous or intravenous anticoagulant before and/or following an invasive procedure.”

Coauthor Sarah A. Spinler, PharmD, FCCP, FAHA, FASHP, AACC, BCPS-AQ Cardiology, Professor of Clinical Pharmacy, Philadelphia College of Pharmacy, University of the Sciences in Philadelphia, pointed out that anticoagulation bridging is a “complex process” that involves the patient and several healthcare providers, including the anticoagulation prescriber, the proceduralist, and possibly an intermediary practitioner (eg, an anticoagulation clinic practitioner).

“While there are other recommendations with respect to bridging that have been published within the last year or so as part of other guidance documents on anticoagulation for venous thromboembolism or nonvalvular atrial fibrillation, this statement was developed with the sole purpose of providing informed decision making of individual practitioners at a depth suitable to implement in practice,” said Dr. Spinler. “More importantly, it was developed with the input of multiple professional associations who have their own information on bleeding and thrombotic risk association with procedures.”

She explained that the report applies only to those with nonvalvular atrial fibrillation, which is the most common indication for anticoagulation.

Some key points of the Decision Pathway as described by Dr. Spinler include the following:

• It is important to document all communication that occurs between the anticoagulation prescriber, anticoagulation clinic, patient, and proceduralist to ensure a safe transition.

• “Direct-acting oral anticoagulants do not require bridging, per se, because of their rapid offset and onset of action,” she said. “However, the duration of action is affected by renal function, and Table 2 (https://www.onlinejacc.org/content/early/2017/01/05/j.jacc.2016.11.024/T4) provides guidance on the duration that these agents need to be held prior to low risk and high risk for bleeding procedures.”

• “Many warfarin-treated patients do not require bridging, and this document may give practitioners confidence to continue anticoagulation through a procedure or not to use injectable heparin as a bridge into or out of the procedure,” she said.

The report also highlights the importance of taking the type of oral anticoagulant, the bleeding risk of both the patient and the procedure, and other patient factors into consideration when deciding whether to interrupt anticoagulation.

The purpose of Expert Consensus Decision Pathways, which were previously known as Expert Consensus Documents, is to “develop policy based on expert opinion in areas for which important clinical decisions are not adequately addressed by available data,” the authors write in the report. They are intended to complement clinical practice guidelines and to provide information that may have been omitted from the guidelines.

Dr. Spinler explained that the current Decision Pathway is a “guidance document” that allows room for individual clinician judgment. She also noted that an app is currently in the works.

“The reach and experience of the ACC is wide and the provision of an app to assist implementation of the pathway will soon be launched,” she said. “Similar apps have been developed by the ACC for other consensus document.”

The Decision Pathway was published in the Journal of the American College of Cardiology. The full-text version is available online.

—Meredith Edwards White

Reference

Periprocedural Management of Anticoagulation Writing Committee, Doherty JU, Gluckman TJ, et al. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. Journal of the American College of Cardiology. 2017 doi: 10.1016/j.jacc.2016.11.024.