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

Abstract

Objective: The objectives of this study were to describe inpatient anticoagulation and bridging in patients with non-valvular atrial fibrillation (NVAF) and to identify whether differences exist in length of stay (LOS) among bridged versus non-bridged NVAF patients. Design: Administrative claims data were used to select patients ‡18 years with a primary or secondary discharge diagnosis of NVAF and inpatient warfarin use from 1 July 2004 to 30 September 2009. Patients with valvular or transient causes of NVAF or pregnancy were excluded. Inpatient bridging was defined as receipt of an anticoagulant in addition to warfarin during the hospitalization. LOS was reported for nonbridged patients (warfarin only) and compared with three bridging regimens: low molecular weight heparin pentasaccharide (LMWH PS); unfractionated heparin (UFH); and two-agent bridging (LMWH PS and UFH). Multivariate analyses were performed to evaluate the association between bridging and LOS, adjusting for demographic and clinical variables. Results: Of 6340 NVAF patients, 48% received inpatient warfarin (mean LOS 5.5 days); among them, 64% received bridging therapy (mean LOS 6.3 days) [LMWH PS 45% (mean LOS 5.6 days), UFH 36% (mean LOS 6.0 days), two-agent bridging 18% (mean LOS 8.4 days)]. Following multivariate analysis, relative to patients who received inpatient warfarin only, LOS was significantly higher for patients with UFH (19.3%) and patients with two-agent bridging (45.1%). Patients with pre-period warfarin, cancer, or diabetes mellitus who received bridging agents had significantly longer LOS than patients with those conditions who were not bridged. Conclusion: LOS was longer for bridged than non-bridged patients. Further studies are needed to identify predictors of bridging and to explain why bridged NVAF patients had longer LOS.

Short‐Term Risk of Bleeding During Heparin Bridging at Initiation of Vitamin K Antagonist Therapy in More Than 90 000 Patients With Nonvalvular Atrial Fibrillation Managed in Outpatient Care

“…First, recommendations in guidelines9, 10, 12 and summaries of product characteristics14, 15 do not strongly advise against bridging therapy. Indeed, several health professionals have criticized the lack of clarity of these guidelines 17, 18, 19, 42, 43…”

“…The recommendation in guidelines9, 10, 12 and summaries of product characteristics14, 15 is less clear for those with stable NVAF who do not require rapid anticoagulation. In real‐life conditions, a bridging regimen is commonly used in those with a low stroke risk 16, 17, 18, 19. This practice is not supported by evidence.…”

Bridging Therapy: A Challenging Area in the Management of Patients with Atrial Fibrillation

“…The findings of SmoyerTomic et al [5]. also indicated that LMWH (63.1%) was the most commonly used agent, followed by UFH (54.6%), bivalirudin (1.2%), fondaparinux (0.8%), and argatroban (0.1%).…”

“…Just as Smoyer-Tomic et al [5]. note in their limitations, their study fails to ascertain the reason for bridging therapy and longer LOS amongst bridging than amongst nonbridging patients.…”

“…A study published recently by Smoyer-Tomic et al [5] found that amongst 3037 inpatients with AF for medical (70%) or surgical admissions (30%), there were 1944 (64%) patients who received bridging therapy. Given the exclusion of pulmonary embolism (PE) and cardiac surgery in this observational study, the real rate of bridging therapy could possibly be even higher among inpatients with AF.…”