How to manage a patient with aortic stenosis who experiences a spontaneous bleed while on anticoagulation therapy?

Management of Spontaneous Bleeding in Patients with Aortic Stenosis on Anticoagulation

For patients with aortic stenosis who experience spontaneous bleeding while on anticoagulation therapy, immediately assess bleeding severity and temporarily discontinue anticoagulation for major bleeding while implementing appropriate hemostatic measures. 1

Bleeding Assessment Algorithm

Step 1: Determine Bleeding Severity

Assess for any of the following factors:

• Bleeding at a critical site 1
• Hemodynamic instability 1
• Clinically overt bleeding with hemoglobin decrease ≥2 g/dL or administration of ≥2 units RBCs 1

If any of these factors are present, the bleed is considered major. If none are present, the bleed is considered non-major. 1

Step 2: Implement Immediate Management Based on Severity

For Major Bleeding:

• Stop oral anticoagulation and any antiplatelet agents 1
• If the patient is on a vitamin K antagonist (VKA), administer 5-10 mg IV vitamin K 1
• Provide local therapy and manual compression 1
• Initiate supportive care and volume resuscitation 1
• Assess and manage comorbidities that could contribute to bleeding (e.g., thrombocytopenia, uremia, liver disease) 1
• Consider surgical/procedural management of the bleeding site 1

For life-threatening or critical site bleeding:

• Administer appropriate reversal/hemostatic agents 1:
  • For VKAs: prothrombin complex concentrates (PCCs), plasma, vitamin K 1
  • For DOACs: specific reversal agents (idarucizumab for dabigatran; andexanet alfa for apixaban or rivaroxaban) 1, 2

For Non-Major Bleeding:

• Stop oral anticoagulation temporarily 1
• Provide local therapy and manual compression 1
• If on a VKA, consider 2-5 mg PO/IV vitamin K 1
• Provide supportive care and volume resuscitation 1
• If applicable, consider stopping antiplatelet agents 1
• Assess for and manage comorbidities that could contribute to bleeding 1

For minor, superficial bleeding:

• Consider continuing anticoagulation while applying local measures 3
• Apply hemostatic agents like Surgicel directly to the wound with gentle pressure 3

Special Considerations for Aortic Stenosis

Patients with aortic stenosis require additional considerations:

• Maintain adequate preload as these patients are preload-dependent 4
• Avoid hypotension which can lead to clinical decompensation 4
• If hypotension occurs, use vasopressors at the lowest effective dose 4
• Monitor closely for signs of heart failure exacerbation 4, 5

Restarting Anticoagulation

Once bleeding is controlled and the patient is stable, assess if there is a clinical indication for continued anticoagulation: 1

Delay or Discontinue Anticoagulation If:

• Bleeding occurred at a critical site 1
• Patient is at high risk of rebleeding or death/disability with rebleeding 1
• Source of bleed has not been identified 1
• Surgical or invasive procedures are planned 1

Restart Anticoagulation If:

• The bleeding source has been identified and controlled 1
• The risk of thromboembolism outweighs the risk of recurrent bleeding 1
• For patients with mechanical valves or high thrombotic risk, consider restarting anticoagulation as soon as hemostasis is achieved 1, 6

Important Caveats and Pitfalls

• Patients with aortic stenosis are particularly vulnerable to hemodynamic compromise during bleeding episodes 4
• Rapid reversal of anticoagulation may increase thrombotic risk, especially in patients with aortic stenosis who may have concomitant coronary artery disease 7, 6
• When restarting anticoagulation, consider using a bridging strategy with shorter-acting agents in high-risk patients 1
• For patients who have undergone TAVI, bleeding risk is particularly high and requires careful management of antithrombotic therapy 6
• Bivalirudin may be considered as an alternative anticoagulant in patients with heparin-induced thrombocytopenia 8