Acute coronary syndrome in patients treated by vitamin K antagonists or non‿vitamin K antagonist oral anticoagulants: Proposed management algorithm for the first 48 hours

Around 10% of patients with acute coronary syndrome are treated by vitamin K antagonists or non‿vitamin K antagonist oral anticoagulants for various indications. The initial management of these patients is highly complex, and new guidelines specify that, only during percutaneous coronary intervention, a bolus of unfractionated heparin is recommended in one of the following circumstances: (1) if the patient is receiving a non‿vitamin K antagonist oral anticoagulant; or (2) if the international normalized ratio is < 2.5 in a patient being treated with a vitamin K antagonist. In this review we report on five key messages essential for the management of these patients. There are no randomized studies to date, and we propose two diagnostic and/or therapeutic decision algorithms. However, randomized studies are needed to validate these strategies.