Practice Guidelines

Bleeding with Anticoagulants: ACC Releases Expert Consensus Decision Pathway to Guide Management


Am Fam Physician. 2018 Jul 1;98(1):57-58.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• One or more of the following factors qualify bleeding as a major event: critical site location, hemodynamic instability, bleeding with a decrease in hemoglobin of at least 2 g per dL (20 g per L) or requiring at least 2 units of red blood cells.

• Major and nonmajor bleeding requiring hospitalization, surgery, or transfusion should be controlled and oral anticoagulants discontinued.

• Major life-threatening bleeding or bleeding at a critical site warrant a reversal agent.

From the AFP Editors

More than 6 million persons in the United States are taking anticoagulants for a number of conditions, including venous thromboembolism and atrial fibrillation. These patients have an increased risk of bleeding, which is associated with a greater risk of morbidity and mortality. This Expert Consensus Decision Pathway from the American College of Cardiology (ACC) aims to provide physicians with decision-making assistance for managing bleeding events in patients taking anticoagulants.

Major Bleeding Events

Bleeding is considered to be a major event if it occurs at a critical site, there is accompanying hemodynamic instability, or there is bleeding with a decrease in hemoglobin of at least 2 g per dL (20 g per L) or at least 2 units of red blood cells are transfused. Critical site bleeding includes airway, extremity, intra-abdominal, and intracranial and other central nervous system bleeding; pericardial tamponade; hemothorax; and retroperitoneal hematoma. Symptoms of airway bleeding include hemoptysis, shortness of breath, epistaxis, and hypoxia. Symptoms of extremity bleeding include pain, swelling, pallor, paresthesia, weakness, weak pulse, and decreased range of motion, and can result in compartment syndrome, paralysis, joint damage, and limb loss. Symptoms of intra-abdominal bleeding include pain, distension, hypotension, and tachycardia. Symptoms of intracranial bleeding include intense headache, emesis, and neurologic signs such as reduced level of

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of Practice Guidelines published in AFP is available at



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