Bridging Anticoagulation: Primum Non Nocere
Bridging Anticoagulation: Primum Non Nocere
Chronic oral anticoagulation frequently requires interruption for various reasons and durations. Whether or not to bridge with heparin or other anticoagulants is a common clinical dilemma. The evidence to inform decision making is limited, making current guidelines equivocal and imprecise. Moreover, indications for anticoagulation interruption may be unclear. New observational studies and a recent large randomized trial have noted significant perioperative or periprocedural bleeding rates without reduction in thromboembolism when bridging is employed. Such bleeding may also increase morbidity and mortality. In light of these findings, physician preferences for routine bridging anticoagulation during chronic anticoagulation interruptions may be too aggressive. More randomized trials, such as PERIOP2 (A Double Blind Randomized Control Trial of Post-Operative Low Molecular Weight Heparin Bridging Therapy Versus Placebo Bridging Therapy for Patients Who Are at High Risk for Arterial Thromboembolism), will help guide periprocedural management of anticoagulation for indications such as venous thromboembolism and mechanical heart valves. In the meantime, physicians should carefully consider both the need for oral anticoagulation interruption and the practice of routine bridging when anticoagulation interruption is indicated.
More than 35 million prescriptions for oral anticoagulation (OAC) are written each year in the United States. Conditions being treated with OAC include atrial fibrillation, mechanical heart valves, venous or arterial thromboembolism, and ventricular assist devices. In any given year, 15% to 20% of these patients will undergo an invasive procedure or surgery that interrupts their chronic OAC, putting them at increased risk for thromboembolism (TE), hemorrhage, and death. Perioperative or periprocedural (hereafter combined simply as periprocedural) anticoagulation management is a common clinical dilemma, often leading to significant adverse events. The clinical relevance of this common dilemma and the lack of definitive evidence to guide medical decision making has finally led to the conduct of pertinent clinical trials, 1 of which has been recently completed. However, current guidelines from the American Heart Association, American College of Cardiology, Heart Rhythm Society, and American College of Chest Physicians have yet to incorporate the findings of this trial and remain based upon observational studies and expert opinion. Yet, the guidelines do largely agree upon 3 important principles:
Patients at low risk for TE should not create a clinical dilemma. Yet, physician surveys of periprocedural bridging preferences demonstrate that approximately 30% of physicians choose to bridge patients at low risk for TE due to overestimation of thrombosis risk. There is even greater heterogeneity of practice in those patients with intermediate or unclear risks of bleeding or TE. Current evidence, including the recently completed BRIDGE trial (Bridging Anticoagulation in Patients Who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery) (see later discussion), suggests that periprocedural bleeding rates are significantly higher than thrombosis rates in this group.
The goal of this review is not to detail the timing, doses, or specifics of bridging anticoagulation. Rather, we will review the data available to specific questions that arise in clinical practice to better individualize decision making and reduce adverse events. We have limited the scope of the discussion to anticoagulant management. The periprocedural management of antiplatelet agents has been reviewed elsewhere.
Abstract and Introduction
Abstract
Chronic oral anticoagulation frequently requires interruption for various reasons and durations. Whether or not to bridge with heparin or other anticoagulants is a common clinical dilemma. The evidence to inform decision making is limited, making current guidelines equivocal and imprecise. Moreover, indications for anticoagulation interruption may be unclear. New observational studies and a recent large randomized trial have noted significant perioperative or periprocedural bleeding rates without reduction in thromboembolism when bridging is employed. Such bleeding may also increase morbidity and mortality. In light of these findings, physician preferences for routine bridging anticoagulation during chronic anticoagulation interruptions may be too aggressive. More randomized trials, such as PERIOP2 (A Double Blind Randomized Control Trial of Post-Operative Low Molecular Weight Heparin Bridging Therapy Versus Placebo Bridging Therapy for Patients Who Are at High Risk for Arterial Thromboembolism), will help guide periprocedural management of anticoagulation for indications such as venous thromboembolism and mechanical heart valves. In the meantime, physicians should carefully consider both the need for oral anticoagulation interruption and the practice of routine bridging when anticoagulation interruption is indicated.
Introduction
More than 35 million prescriptions for oral anticoagulation (OAC) are written each year in the United States. Conditions being treated with OAC include atrial fibrillation, mechanical heart valves, venous or arterial thromboembolism, and ventricular assist devices. In any given year, 15% to 20% of these patients will undergo an invasive procedure or surgery that interrupts their chronic OAC, putting them at increased risk for thromboembolism (TE), hemorrhage, and death. Perioperative or periprocedural (hereafter combined simply as periprocedural) anticoagulation management is a common clinical dilemma, often leading to significant adverse events. The clinical relevance of this common dilemma and the lack of definitive evidence to guide medical decision making has finally led to the conduct of pertinent clinical trials, 1 of which has been recently completed. However, current guidelines from the American Heart Association, American College of Cardiology, Heart Rhythm Society, and American College of Chest Physicians have yet to incorporate the findings of this trial and remain based upon observational studies and expert opinion. Yet, the guidelines do largely agree upon 3 important principles:
OAC should not be interrupted for procedures with low bleeding risk.
Patients at highest risk for TE without excessive bleeding risk should consider bridging. Conversely, those at low risk for TE should not be bridged.
Intermediate-risk cases (Table 1) should be managed by individually considering patient- and procedure-specific risks for bleeding and TE.
Patients at low risk for TE should not create a clinical dilemma. Yet, physician surveys of periprocedural bridging preferences demonstrate that approximately 30% of physicians choose to bridge patients at low risk for TE due to overestimation of thrombosis risk. There is even greater heterogeneity of practice in those patients with intermediate or unclear risks of bleeding or TE. Current evidence, including the recently completed BRIDGE trial (Bridging Anticoagulation in Patients Who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery) (see later discussion), suggests that periprocedural bleeding rates are significantly higher than thrombosis rates in this group.
The goal of this review is not to detail the timing, doses, or specifics of bridging anticoagulation. Rather, we will review the data available to specific questions that arise in clinical practice to better individualize decision making and reduce adverse events. We have limited the scope of the discussion to anticoagulant management. The periprocedural management of antiplatelet agents has been reviewed elsewhere.
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