Bridge Therapy Outcomes in Patients With Mechanical Heart Valves

Delate, Thomas; Meisinger, Stephanie M.; Witt, Daniel M.; Jenkins, Daniel E.; Douketis, James D.; Clark, Nathan P.

doi:10.1177/1076029616669786

Cited by 8 publications

(6 citation statements)

References 22 publications

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“…To understand why current bridging practice is not always in line with guideline recommendations we aimed to identify characteristics associated with bridging use. The associations found for atrial fibrillation, mechanical heart valve and venous thromboembolism patients correspond with the findings of others where most atrial fibrillation patients did not receive bridging and most mechanical heart valve and venous thromboembolism patients were at least at moderate thromboembolic risk justifying bridging anticoagulation use [14, 35, 36]. Regarding, the aggregated AT9 thromboembolic risk strata, the moderate and high risk strata were more likely to receive bridging, which is to be expected.…”

Section: Discussionsupporting

confidence: 85%

Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance

et al. 2019

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Background Bridging anticoagulation is used in vitamin-K antagonist (VKA) patients undergoing invasive procedures and involves complex risk assessment in order to prevent thromboembolic and bleeding outcomes. Objectives Our aim was to assess guideline compliance and identify factors associated with bridging and especially, non-compliant bridging. Methods A retrospective review of 256 patient records in 13 Dutch hospitals was performed. Demographic, clinical, surgical and care delivery characteristics were collected. Compliance to the American College of Chest Physicians ninth edition guideline (AT9) was assessed. Multilevel regression models were built to explain bridging use and predict non-compliance. Results Bridging use varied from 15.0 to 83.3% (mean = 41.8%) of patients per hospital, whereas guideline compliance varied from 20.0 to 88.2% (mean = 68.5%) per hospital. Both established thromboembolic risk factors and characteristics outside thromboembolic risk assessment were associated with bridging use. Predictors for overuse were gastrointestinal surgery (OR 14.85, 95% CI 2.69–81.99), vascular surgery (OR 13.01, 95% CI 1.83–92.30), non-elective surgery (OR 8.67, 95% CI 1.67–45.14), lowest 25th percentile socioeconomic status (OR 0.33, 95% CI 0.11–1.02) and use of VKA reversal agents (OR 0.22, 95% CI 0.04–1.16). Conclusion Bridging anticoagulation practice was not compliant with the AT9 in 31.5% of patients. The aggregated AT9 thromboembolic risk was inferior to individual thromboembolic risk factors and other characteristics in explaining bridging use. Therefor the AT9 risk seems less important for the decision making in everyday practice. Additionally, a heterogeneous implementation of the guideline between hospitals was found. Further research and interventions are needed to improve bridging anticoagulation practice in VKA patients. Electronic supplementary material The online version of this article (10.1186/s12959-019-0204-x) contains supplementary material, which is available to authorized users.

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Section: Discussionsupporting

confidence: 85%

Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance

et al. 2019

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“…It would be dangerous to reverse the anticoagulant action until the bleeding ceases completely. Hence, patients need to receive bridging heparin therapy, and monitoring is necessary until they reach the therapeutic range of INR [ 20 ]. Kuramatsu et al recently reported on anticoagulation management after acute intracerebral hemorrhage (ICH) in patients requiring long-term OAC due to the presence of mechanical heart valves [ 6 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical outcomes of gastrointestinal bleeding management during anticoagulation therapy

et al. 2022

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Background Acute gastrointestinal (GI) bleeding is not an uncommon complication of oral anticoagulation (OAC) therapy that requires medication cessation. However, drug cessation may cause fatal stroke or systemic embolization in patients at high thromboembolic risk. Here we sought to find an appropriate anticoagulation cessation strategy in cases of GI bleeding during OAC therapy. Methods This single-center retrospective cohort analysis was performed between 2010 and 2018. Patients were enrolled if the following three consecutive conditions were met: 1) electrocardiography electrocardiography-proven atrial fibrillation; 2) OAC therapy; and 3) GI bleeding. We divided the drug cessation strategy into the continuation and discontinuation groups. During 1-year follow-up, the rates of major thromboembolic and rebleeding events were calculated. Results One hundred and forty-six patients (continuation [n = 54] vs. discontinuation [n = 92] group) were enrolled. Patients in the discontinuation group were more likely to be older (69.8 ± 9.0 yrs vs. 74.9 ± 8.9 yrs, p = 0.001), while patients in the continuation group were more likely to have undergone cardiac valve surgery (51.9% vs. 20.7%, p<0.001). The presence of a mechanical mitral valve was a determinant of continuation strategy (38.9% vs. 7.5%, p<0.001). However, the mean CHA₂DS₂-VASc (3.4±1.3 vs. 4.1±1.6, p = 0.010) and Glasgow-Blatchford (8.0±2.4 vs. 8.9±2.5, p = 0.037) scores were higher in the discontinuation group. Two major embolic strokes occurred in each group (3.7% vs. 2.2%, p = 0.585). Four of 54 (7.4%) and five of 92 (5.4%) patients had rebleeding events during follow-up (p = 0.632). One embolic event in the continuation group and one rebleeding event in the discontinuation group were fatal. The Glasgow-Blatchford score was a predictor of 1-year rebleeding events (odds ratio [OR], 1.36; 95% confidence interval [CI], 0.68–2.20; p = 0.028). The high CHA₂DS₂-VASc score showed a strong trend (OR, 1.71; 95% CI, 0.92–3.20; p = 0.089) in 1-year thromboembolic events. Conclusion No single risk factor or drug cessation strategy was attributed to adverse clinical events after GI bleeding. The risk of future thrombotic or rebleeding events should be individualized and controlled for based on a pre-existing stratification system.

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“…However, prospective data to support this approach is minimal and the paradigm is currently undergoing investigation (NCT00432796). 5…”

Section: Assessing Thromboembolic Riskmentioning

confidence: 99%

Peri-Procedural Management of Oral Anticoagulants in the DOAC Era

Barnes

Mouland

2018

Progress in Cardiovascular Diseases

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Peri-procedural management of oral anticoagulants can be complex and confusing for many providers. It involves a careful balance of a patient's thromboembolic risk and bleeding risk. For every patient chronically taking an oral anticoagulant who will be undergoing an elective procedure, a four step approach may be considered when creating a plan for the oral anticoagulant. (1) Does the oral anticoagulant need to stop for the procedure? (2) If yes, when should the oral anticoagulant be stopped pre-procedure? (3) Does the patient require a "bridging" parenteral anticoagulant? (4) When should anticoagulation be re-started post procedure? Based on the unique features of warfarin versus the direct oral anticoagulants (DOAC), a unique, personalized plan should be developed and tailored to the individual patient. Anticoagulant specialists, such as anticoagulation clinic pharmacists, may help facilitate this process.

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Bridge Therapy Outcomes in Patients With Mechanical Heart Valves

Abstract: The use of bridge therapy is common among patients with MHV and may be associated with increased bleeding risk. Further research is needed to determine whether bridge therapy reduces TE in patients with MHV interrupting warfarin for invasive procedures.

Cited by 8 publications

References 22 publications

Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance

Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance

Clinical outcomes of gastrointestinal bleeding management during anticoagulation therapy

Peri-Procedural Management of Oral Anticoagulants in the DOAC Era

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