Sara Altayeb: ESC 2026 Clinical Pearls for Bleeding on Anticoagulation
Sara Altayeb, Internal Medicine Specialist at Virtual Sudan Clinic, shared on LinkedIn:
”Bleeding on Anticoagulation | ESC 2026 Clinical Pearls:
Managing bleeding isn’t just about stopping drugs, it’s about risk stratification plus targeted reversal plus safe restart.
1. Classify First (ESC Approach):
- Minor / self-limited
- Clinically relevant non-major (CRNM)
- Major / Life-threatening
Severity drives everything!
2. What Defines Major Bleeding?
- Hemodynamic instability
- Hb drop ≥ 2 g/dL or transfusion ≥ 2 units
- Critical site (intracranial, GI, retroperitoneal)
Treat immediately!!
3. Know Your Anticoagulant!
- Warfarin (VKA) – check INR
- DOACs – consider last dose + renal function
- Heparin – short half-life (rapid offset)
Drug plus timing equals management strategy!
4. Management by Severity:
Minor:
- Continue anticoagulant
- Local measures only
CRNM:
- Temporarily hold drug
- Treat source
- Review dose and interactions
Major Bleeding:
- Stop anticoagulant
- ABC resuscitation first
- Use reversal
ESC Reversal Pearls:
- Warfarin – PCC + Vitamin K
- Dabigatran – Idarucizumab
- Apixaban/Rivaroxaban – Andexanet alfa (if available) or PCC
- Heparin – Protamine
5. Restarting Anticoagulation:
Restart early once hemostasis achieved
- High thrombotic risk – restart sooner
- Intracranial bleed – delay and individualize
‘Don’t forget why the patient was anticoagulated.’
Take-Home: Classify – Stabilize – Reverse (if needed) – Restart safely.”
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