ACC Issues Guidelines for Atrial Fibrillation Treatment Interruption

The American College of Cardiology has released a series of revised recommendations with the intention of helping clinicians determine whether patients with atrial fibrillation on anticoagulants should stop taking the medications ahead of scheduled surgeries, and, if so, for how long.

The ACC committee writing the recommendations emphasizes the need for collaborative discussion with patients as to the risks and benefits of temporarily halting anticoagulant therapy. The committee also urges clearly documenting anticoagulant management plans and patient concurrence in patients' medical records before undertaking surgery, in order to minimize treatment errors.
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Patient factors linked to bleeding risk include hypertension, abnormal renal function, abnormal liver function, prior stroke, history of or predisposition to anemia, age over 65 years old, and consuming 8 or more alcoholic drinks on a weekly basis, the authors note, adding that other risks exist as well.

The recommendations the authors make for patients on warfarin or another vitamin K antagonist include continuing therapy without interruption in patients undergoing procedures with low or not clinically important bleed risk and no patient-related factors that increase the risk of bleeding. The committee also suggests temporarily interrupting treatment in patients undergoing procedures with intermediate or high bleed risk or patients undergoing procedures with uncertain bleed risk and the presence of patient-related factors that increase bleeding risk.

In terms of how vitamin K antagonists should be interrupted, the authors' recommendations include discontinuing therapy 3 to 4 days ahead of the procedure in patients with international normalized ratios (INRs) of 1.5 to 1.9, if a normal INR is desired, and discontinuing therapy at least 5 days prior to the procedure in patients with INRs greater than 3.0.

"This pathway makes decision making easier, especially regarding whether anticoagulation needs to be interrupted and whether the patient needs to be bridged," said writing committee chair John U. Doherty, MD, a professor and physician at Thomas Jefferson University in Philadelphia.

"The result is that patients with very low bleeding risk procedures and no patient-related bleeding risks can often be managed without interruption. By following the guidance of this pathway, the primary care physician will be in a position to make evidence-based recommendations to the care team. By reserving bridging to high thrombotic risk patients, fewer patients will need to be bridged with a parenteral agent."

—Mark McGraw

Reference:

Doherty JU, Gluckman TJ, Hucker WJ, et al; Periprocedural Management of Anticoagulation Writing Committee. 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force [published online January 9, 2017]. J Am Coll Cardiol. doi:10.1016/j.jacc.2016.11.024.