ACC 2020 — Expert Consensus Decision Pathway on Management of Bleeding on Oral Anticoagulants
American College of Cardiology, 2020
For life-threatening bleeding: reverse Dabigatran with Idarucizumab 5 g IV; reverse Factor Xa inhibitors with 4F-PCC (institutional protocol; commonly 25–50 U/kg). Andexanet alfa has historical efficacy data but is discontinued in the U.S. as of 2026; reverse Warfarin with 4F-PCC (25-50 U/kg) plus IV Vitamin K 10 mg; reverse Unfractionated Heparin with Protamine sulfate.
Clinical Context & Relevant Topics (3)
Disease ReferenceUFH vs LMWH vs DTIs (Argatroban/Bivalirudin), anti-Xa vs aPTT monitoring, and emergency reversal (Protamine, 4F-PCC, Idarucizumab; historical andexanet evidence with current availability caveats).
The trauma lethal diamond (hypothermia, acidosis, coagulopathy, hypocalcemia), 1:1:1 massive transfusion (PROPPR trial), early TXA (CRASH-2), and TEG/ROTEM algorithms.
Risk-stratified non-variceal and variceal hemorrhage care: resuscitation, selective airway protection, individualized transfusion, PPI or portal-pressure therapy, endoscopic hemostasis, and escalation to IR/TIPS/surgery when indicated.