Classification and Management of Bleeding Events

Definition and Classification of Major Bleeding

The American College of Cardiology defines major bleeding as an event that meets at least one of the following criteria: bleeding at a critical site, hemodynamic instability, or clinically overt bleeding with hemoglobin decrease ≥2 g/dL or administration of ≥2 units of red blood cells 1, 2, 3
Bleeding at a critical site includes intracranial, intraocular, spinal, thoracic, airway, pericardial, intra-abdominal, retroperitoneal, intra-articular, or intramuscular bleeding 3, 4
Hemodynamic instability is defined as systolic BP <90 mmHg, BP drop >40 mmHg, orthostatic changes, mean arterial pressure <65 mmHg, heart rate elevation, or urine output <0.5 mL/kg/h 3, 4

For patients with non-major gum bleeding and ecchymosis, the American College of Cardiology recommends considering continuing oral anticoagulation if there is an appropriate indication 5
Local therapy with manual compression using gauze soaked in tranexamic acid is recommended for gum bleeding 5
Assessment for and management of comorbidities contributing to bleeding, such as thrombocytopenia, uremia, or liver disease, is necessary 5, 4

If the patient is hemodynamically unstable or has a hemoglobin drop ≥2 g/dL, the American College of Cardiology recommends stopping oral anticoagulation immediately 5, 4
Administration of reversal/hemostatic agents, such as vitamin K, may be necessary for patients with major bleeding 5, 4
Supportive care and volume resuscitation are essential for patients with major bleeding 5, 4

The American College of Cardiology advises against automatically classifying all visible bleeding as major bleeding, as this requires objective hemodynamic or laboratory parameters 1, 2
Reversal agents, such as prothrombin complex concentrates, idarucizumab, and andexanet alfa, should only be administered for major bleeding events 3, 5