Antithrombotic therapy can be divided into three categories: Anticoagulant agents, antiplatelet agents, and fibrinolytic agents. Important considerations for reversal of antithrombotic therapy include the following:

• Underlying need for anticoagulation therapy
• Underlying need for reversal
• Risk for immediate thrombosis due to acute reversal of anticoagulation therapy
• Timing of last dose of anticoagulant
• Potential for associated coagulopathies
  • Associated organ disease or failure (e.g. liver or renal) as contributing factors to bleeding complications
  • Thrombocytopenia or platelet dysfunction due to any etiology or concomitant medications
• Reversal agents and their efficacy
• Need for consultation with hematology service in complex cases
• Emergent or elective surgical interventions

Criteria for reversal of antithrombotic therapy in the event of bleeding:

• Classify bleeding as “major” or “minor” as follows:
  • Major bleeding in non-surgical patients:
    • Bleeding associated with a significant risk of death (e.g. intracranial bleeding or catastrophic gastrointestinal bleeding)
    • Bleeding associated with hemodynamic instability (e.g. intra-abdominal bleeding)
    • Bleeding associated with long-term morbidity (e.g. intraocular bleeding, intracranial hemorrhage, soft tissue/muscle bleeding leading to compartment syndrome)
    • Bleeding in a noncompressible vessel (e.g. subclavian)

Most other events may be considered “minor” with consideration that immediate reversal may not be required. Each clinical scenario may pose different challenges, and individual patient risks must be considered.

Reversal criteria for emergent surgical/procedural interventions

The decision for reversal should be weighed based on the “risk of bleeding during surgery” versus the “immediate risk of thrombosis” due to reversal of anticoagulation.

Every clinical scenario should be treated on an individual basis and one should take into account if and when anticoagulation therapy is to be resumed after surgery/procedure.

The following surgical procedures generally do not require anticoagulation reversal:

• Placement of PICC lines, placement of tympanostomy tubes, chest tube removal
• Minor dental procedures
• Minor dermatological procedures
• Cataract surgery
• Select cardiac procedures (cardiac implantable devices, endovascular procedures)

Updates from the ACCP 10th Edition Guidelines for Antithrombotic Therapy (AT10)¹

• In patients with deep vein thrombosis (DVT) of the leg or pulmonary embolism (PE) and no cancer: dabigatran, rivaroxaban, apixaban, or edoxaban are preferred over vitamin K antagonist (VKA)
• In patients with DVT or PE and cancer, LMWH is recommended over VKA or NOACs
• In patients with an unprovoked proximal DVT or PE who are stopping anticoagulant therapy and have no contraindication, consider aspirin to prevent recurrent VTE
• In patients with subsegmental PE and no proximal DVT who have low risk for VTE recurrence, consider clinical surveillance over anticoagulation. Start anticoagulation for patients with high risk of recurrent VTE
• Administer thrombolytic therapy in patients with acute PE associated with hypotension (SBP <90 mm Hg) who do not have a high bleeding risk
• Administer thrombolytic therapy in selected patients with acute PE who deteriorate after starting anticoagulant therapy but have not yet developed hypotension and who have a low bleeding risk
• Systemic thrombolysis using a peripheral vein is preferred over catheter-directed thrombolysis (CDT) in acute PE. CDT should be reserved for patients with acute PE associated with hypotension and high bleeding risk, failed systemic thrombolysis, and/or shock that is likely to cause death before systemic thrombolysis can take effect
• Recurrent VTE on VKA or NOAC therapy: suggest switching to treatment with LMWH at least temporarily (1 month)
• Recurrent VTE on LMWH (and compliant): increase dose of LMWH by 25% to 30%

Risk factors for bleeding (ACCP AT10)¹

• Age
• Previous bleeding
• Cancer
• Thrombocytopenia
• Previous stroke
• Diabetes
• Anemia
• Antiplatelet therapy
• Poor anticoagulant control
• Comorbidity and reduced functional capacity
• Metastatic cancer
• Renal failure
• Liver failure
• Recent surgery
• Frequent falls
• Alcohol abuse
• Nonsteroidal anti-inflammatory drugs

Estimated Absolute Risk of Major Bleeding (ACCP AT10)¹

• Low Risk
  • No. of Risk Factors – 0
  • Estimated Absolute Risk of Major Bleeding (%) – 1.6
• Moderate Risk
  • No. of Risk Factors – 1
  • Estimated Absolute Risk of Major Bleeding (%) – 3.2
• High Risk
  • No. of Risk Factors – >2
  • Estimated Absolute Risk of Major Bleeding (%) – 12.8