Roundtable Discusses Periprocedural Management of Anticoagulation and Management of Bleeding

Williams HeadshotThis post was authored by ACC President Kim Allan Williams Sr., MD, FACC.

Anticoagulation management is a rapidly-evolving field, presenting challenges to clinicians across a broad range of specialties. With new reversal agents on the horizon, there is a critical need for guidance. In an effort to better guide clinicians to address the evolving challenges of anticoagulation care, the ACC brought together a number of stakeholders across the health care spectrum for its third Anticoagulation Consortium Roundtable this past weekend.

This meeting continued the discussions started in 2013 when the first Anticoagulation Consortium Roundtable examined issues in anticoagulation treatment and ways to reduce gaps in care. Last year, the second Roundtable covered key questions facing providers, as well as patient barriers and evolving treatment options. I’m encouraged by the progress made in the past two years. At the first meeting, the PINNACLE Registry showed a little more than 50 percent of providers providing optimal treatment based on clinical guidelines. Now we are seeing percentages in the low to mid-60s. While that means that a significant amount of patients remain untreated despite high-risk of stroke, we are making progress!

ACC's Anticoagulation Initiative Work Group

ACC’s Anticoagulation Initiative Work Group

In the first part of the meeting, robust discussions took place on topics surrounding periprocedural management of anticoagulation, particularly bridging therapy. Thomas Ortel, MD, PhD, kicked-off the Roundtable with a review of the BRIDGE Trial, which compared a strategy of anticoagulation interruption with low molecular weight heparin bridge therapy among patients with atrial fibrillation undergoing an invasive procedure. Findings showed that the low molecular weight heparin bridging therapy did not prevent perioperative arterial thromboembolism, but did increase bleeding risk, and that clinicians should be cautious and evaluate patients when considering bridging. Ortel noted that with an estimated 250,000 patients in North America alone requiring temporary interruption of oral anticoagulant therapy for an operation or invasive procedure each year, the need for better anticoagulation management is great. While there are limitations to this study, which only included patients on warfarin and not direct oral anticoagulants (DOACs), it begins to demonstrate insights into periprocedural management and the importance of considering multiple factors when balancing stroke and bleed risk.

The tools and resources available to help clinicians offer better anticoagulation care were also discussed. Ty Gluckman, MD, FACC, showed how clinical mobile apps, like those offered by the ACC, can offer timely solutions. “Building a medical app starts with identifying a problem that can be improved by a point of care tool that supports better clinical decision-making and/or improved patient outcomes,” said Gluckman. He added that ACC’s ASCVD Risk Estimator App, which was voted the best medical app released in 2014, is a great example of an app that followed this process.

ACC President Kim Allan Williams Sr., MD, FACC, offering opening remarks during the Anticoagulation Consortium Roundtable

ACC President Kim Allan Williams Sr., MD, FACC, offering opening remarks during the Anticoagulation Consortium Roundtable

Management of bleeding was another important clinical challenge that participants discussed. Laboratory measurement of the DOACs and bleed management within the hospital were some of the topics addressed. Participants examined current assays and bleed management techniques in practice, and offered recommendations for how to manage potential gaps in care.

The meeting ended with an overview of reversal agents in development and their potential impact on practice. Participants anticipated reactions in the field and assessed educational needs and opportunities. The ACC received several suggestions for helping direct the use of reversal agents and improving outcomes – including creating a new registry and educating patients and providers.

Overall, this year’s Anticoagulation Consortium Roundtable achieved its goal of uncovering the challenges faced by clinicians in each participant’s specialty area. Roundtable Co-Chair Greg C. Flaker, MD, FACC, closed the meeting by urging participants to bring the challenges discussed back to their societies. He added that the valuable input received during the meeting will help to steer ACC’s work to support the broader community caring for patients on anticoagulants and improve patient outcomes.

The Anticoagulation Consortium Roundtable, an activity of ACC’s Anticoagulation Initiative, was supported by: Boehringer Ingelheim Pharmaceuticals, Inc., Daiichi Sankyo, Inc., Janssen Pharmaceuticals, Inc., and Portola Pharmaceuticals, Inc.

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