A Clinician’s Guide to Perioperative Bridging for Patients on Oral Anticoagulation

Abstract

Updates in recent clinical guidelines have led to a change in the management of perioperative anticoagulation for patients on oral anticoagulant therapy. No standardized bridging consensus exists in the literature. The necessity for bridging therapy is determined based on careful consideration of the thrombosis risk versus the bleeding risk of the procedure. Risk stratification will aid the decision to bridge or not to bridge. Patients are bridged with agents with appropriate kinetics to allow for their elimination prior to the time of the procedure in order to decrease the risk of hemorrhage during invasive procedures. This intent of this article is to discuss perioperative bridging therapy and provide a practical guide for the clinician.

Anticoagulant Use, the Prevalence of Bridging, and Relation to Length of Stay among Hospitalized Patients with Non-Valvular Atrial Fibrillation

“…While the average risk of stroke in NVAF patients not treated with AC is reported to be 4.5%,[22] risk varies considerably depending on age and selected co-morbidities such as diabetes, congestive heart failure, hypertension, and prior stroke or TIA. [25,26] Determining when the risk of thromboembolism is sufficiently high to require bridging during warfarin initiation, during periods of subtherapeutic AC in patients already treated with warfarin, or during interruption of warfarin peri-operatively, is challenging. Two recent reviews, focused on patients undergoing surgery or procedures, have attempted to sort through the available data and to provide guidance to physicians faced with this decision.…”

“…Two recent reviews, focused on patients undergoing surgery or procedures, have attempted to sort through the available data and to provide guidance to physicians faced with this decision. [25,26] Kaatz and Paje[25] cite a 30-day risk of stroke in AF patients with discontinuation of AC and without bridging of 0.6–1.8%, increasing to greater than 3% in patients undergoing more complex surgery. The CHA 2 DS 2 -VASc score provides a means for assessing thromboembolic risk.…”

“…[20] Various approaches have been used, including type and length of the surgical procedure, the significance of the potential bleed, and subjective determination by the physician. [25,26] The HAS-BLED bleeding risk score, which incorporates diagnostic as well as laboratory data such as INR values shows promise,[27] although HAS-BLED cannot readily be applied in studies such as ours, which use administrative claims data. Future research should include factors such as bleeding and thrombosis to better understand clinical decision-making regarding bridging therapy and why it results in longer LOS.…”

Étude rétrospective évaluant les risques hémorragiques et thromboemboliques lors d’avulsions dentaires chez 93 patients habituellement traités par AVK et/ou AAP

“…L'hémostase locale était obtenue par mise en place d'un agent hémostatique résorbable d'oxycellulose dans chaque alvéole type Surgicel W (Ethicon) et par la suture des muqueuses avec du fil résorbable 3/0 Vicryl TM (Ethicon). L'importance du saignement postopératoire était codifiée selon 4 catégories [8] (0 : absence de saignement ; + : saignement faible : filets de sang dans la bouche ; ++ : saignement modéré : petits caillots appendus sur les alvéoles ; +++ : saignement majeur nécessitant une réinter-vention au bloc opératoire). Les contrôles étaient réalisés par les infirmières, en salle de réveil avant la remontée dans le service puis toutes les deux heures et par le chirurgien 6 à 8 heures après l'intervention et le lendemain, juste avant la sortie.…”

“…Martin et al[8] ont décrit différents niveaux de risque thromboembolique en fonction de l'indication des AVK et du score CHADS2 : Chaque lettre du score correspond à un facteur de risque : C pour congestive heart failure (insuffisance cardiaque), H pour hypertension (hypertension artérielle), A pour age (âge supérieur à 75 ans), D pour diabetes (diabète) et S pour stroke (accident vasculaire céré-bral). Aux lettres C, H, A et D correspondent 1 point, à la lettre S correspond 2 points.…”