Management of Spontaneous Bleeding in Patients with Aortic Stenosis on Anticoagulation

Assessment and Initial Management

For patients with aortic stenosis who experience spontaneous bleeding while on anticoagulation therapy, the American College of Cardiology recommends immediately assessing bleeding severity and temporarily discontinuing anticoagulation for major bleeding while implementing appropriate hemostatic measures 1, 2
The American College of Cardiology suggests assessing for bleeding at a critical site, hemodynamic instability, or clinically overt bleeding with hemoglobin decrease ≥2 g/dL or administration of ≥2 units RBCs to determine bleeding severity 1, 2
For major bleeding, the American College of Cardiology recommends stopping oral anticoagulation and any antiplatelet agents, administering 5-10 mg IV vitamin K if the patient is on a vitamin K antagonist, and providing local therapy and manual compression 1, 3

The American College of Cardiology recommends restarting anticoagulation once bleeding is controlled and the patient is stable, if there is a clinical indication for continued anticoagulation, such as a high risk of thromboembolism 1, 2, 3
The American College of Cardiology suggests considering a bridging strategy with shorter-acting agents in high-risk patients when restarting anticoagulation 1, 2

The American College of Cardiology recommends considering the risk of thromboembolism and the risk of recurrent bleeding when deciding whether to restart anticoagulation 1, 2
For patients with mechanical valves or high thrombotic risk, the American College of Cardiology suggests restarting anticoagulation as soon as hemostasis is achieved 1, 2