Managing Anticoagulation and Dual Antiplatelet Therapy in Patients with Active Bleed or Upcoming Procedure: A Scoping Review

Introduction: The aim of this paper is to provide primary care providers and hospitalists with up-to-date guidance surrounding the management of anticoagulation and antiplatelet agents in periprocedural settings and when unexpected bleeding complications arise. Methods: We searched PubMed, Cochrane CENTRAL, and Web of Science using applicable MeSH terms and keywords. No date limits or filters were applied. Articles cited by recent cardiovascular guidelines were also utilized. Results: For direct oral anticoagulants (DOACs) and vitamin K agonists (VKAs), a patient's risk for clot and procedural risk of bleeding should be assessed. Generally, patients considered at high risk for venous thromboembolism (VTE) should be bridged, patients at low risk should forgo bridging therapy, and patients in the intermediate range should be evaluated on a case-by-case basis. Emergent anticoagulation reversal treatment is available for both warfarin (i.e., prothrombin complex concentrate, phytonadione) and DOACs (i.e., idarucizumab for dabigatran reversal; andexanet alfa for apixaban and rivaroxaban reversal). DAPT does not need to be held for paracentesis or thoracentesis and is low risk for those needing urgent lumbar punctures. In patients with clinically significant bleeding, those with percutaneous coronary intervention (PCI) performed in the last three months should resume DAPT as soon as the patient is hemodynamically stable, while patients greater than three months out from PCI at high risk of bleed can be de-escalated to single antiplatelet therapy. Conclusions: Appropriate management of anticoagulation and antiplatelet agents in the periprocedural setting and patients with active bleed remains critical in inpatient management.