Mount Carmel Health Partners Clinical Guidelines Atrial Fibrillation | Page 8

Manage bleeding or supratherapeutic INR:
• Severe or life-threatening bleeding on any anticoagulant: send the patient to the ED with EMS transport.
• Minor bleeding on apixaban, rivaroxaban, edoxaban or dabigatran: assess patient individually. If necessary, hold 1 to 2 doses to
achieve homeostasis, then restart medication.
• Supratherapeutic INR on warfarin:
▫ If INR is 4.5 to 10: hold 1 to 2 doses; check INR more frequently (1 to 3 days). Resume warfarin at adjusted dose when INR
returns to therapeutic range.
▫ If INR is over 10: hold warfarin and give vitamin K 2.5 to 5 mg orally. Check INR more frequently; give additional vitamin K
if needed. Resume warfarin at adjusted dose when INR returns to therapeutic range.
Management of severe/life-threatening bleeding:
Severe GI bleeding or intracranial hemorrhage
• Coumadin: give vitamin K or FFP (Fresh frozen plasma)
• NOAC: give FFP or PCC (Prothrombin complex concentrate)
• Dabigatran (Pradaxa): give Idarucizumab (Praxbind)
Manage periprocedural bridging:
Periprocedural bridging of warfarin and novel OACs should be based on the patient’s thromboembolism risk and the bleeding risk
of the procedure.
In general, the anticoagulant must be discontinued if the surgical bleeding risk is high. Those at very high or high thromboembolic
risk should limit the period without anticoagulation to the shortest possible interval. This typically involves the use of a bridging
agent (e.g., a low molecular weight [LMW] heparin) if the patient's usual anticoagulant is a vitamin K antagonist. Often bridging is
not required for those with very high or high thromboembolic risk who are receiving a direct thrombin inhibitor or factor Xa
inhibitor because of the shorter half-lives of these agents.
TABLE C: Symptoms Associated with AF
Fatigue/tiredness Palpitations
Dyspnea Dizziness
Chest pain Weakness
TABLE D: Signs of Instability
Unstable vital signs Myocardial ischemia
Ongoing chest pain with AF Hypotension
Decompensated heart failure
TABLE E: CHD Risk
Mild: 1 to 2 risk factors; Moderate: 3 risk factors; High ≥4 risk factors
Age (men >45, women >55years) Impaired fasting glucose (101—125)
Cigarette smoking Family history of premature CHD (1st degree relative
<60 years or female 1st degree relative <70 years)
BP >140/90 or on antihypertensive medication Non-HDL cholesterol >160
Low HDL cholesterol (men <40, women <50)
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