Periprocedural bridging anticoagulation in patients with venous thromboembolism: A registry‐based cohort study

Abstract

Background: Use of bridging anticoagulation increases a patient's bleeding risk without clear evidence of thrombotic prevention among warfarin-treated patients with atrial fibrillation. Contemporary use of bridging anticoagulation among warfarintreated patients with venous thromboembolism (VTE) has not been studied. Methods:We identified warfarin-treated patients with VTE who temporarily stopped warfarin for a surgical procedure between 2010 and 2018 at six health systems.Using the 2012 American College of Chest Physicians guideline, we assessed use of periprocedural bridging anticoagulation based on recurrent VTE risk. Recurrent VTE risk and 30-day outcomes (bleeding, thromboembolism, emergency department visit) were each assessed using logistic regression adjusted for multiple procedures per patient.Results: During the study period, 789 warfarin-treated patients with VTE underwent 1529 procedures (median, 2; interquartile range, 1-4). Unadjusted use of bridging anticoagulation was more common in patients at high risk for VTE recurrence (99/171, 57.9%) than for patients at moderate (515/1078, 47.8%) or low risk of recurrence (134/280, 47.86%). Bridging anticoagulation use was higher in high-risk patients compared with low-or moderate-risk patients in both unadjusted (P = .013) and patientlevel cluster-adjusted analyses (P = .031). Adherence to American College of Chest Physicians guidelines in high-and low-risk patients did not change during the study period (odds ratio, 0.98 per year; 95% confidence interval, 0.91-1.05). Adverse events were rare and not statistically different between the two treatment groups.Conclusions: Bridging anticoagulation was commonly overused among low-risk patients and underused among high-risk patients treated with warfarin for VTE.Adverse events were rare and not different between the two treatment groups.

Outcomes in patients undergoing periprocedural interruption of warfarin or direct oral anticoagulants

“…Given the large body of evidence associating bridging therapy with increased bleeding risk, it was unsurprising that the bridged warfarin cohort had a numerically higher bleeding rate than to our unbridged warfarin cohort 2–4 . Our bridged warfarin cohort saw similar outcomes with our DOAC cohort with regard to bleeding and thromboembolic events.…”

“…In contrast, our data were not limited to patients eligible for randomization, therefore representing a potentially more generalizable estimate of adverse event rates. Last, our analysis distinguishes between warfarin‐treated patients into both a bridged and a nonbridged cohort, which is critical given the strong evidence associating use of bridging therapy with increased bleeding risk 2–4 …”

“…Last, our analysis distinguishes between warfarin-treated patients into both a bridged and a nonbridged cohort, which is critical given the strong evidence associating use of bridging therapy with increased bleeding risk. [2][3][4] Despite these strengths, certain limitations must be acknowledged. First, the modest sample sizes and inclusion of patients from one geographic region may limit generalizability.…”

“…For patients with a high risk of thrombotic complications, “bridging” therapy with low molecular weight heparin or other short‐acting parenteral anticoagulants are frequently used while the anticoagulant activity of warfarin wanes or returns to therapeutic range. This practice, however, is associated with higher risk of bleeding compared with those in whom bridging therapy was not initiated 2–4 . In contrast to warfarin, DOACs have both a short half‐life and rapid onset of action, which make them ideal for perioperative use and removes the necessity of bridging anticoagulation 5,6 .…”

Applying population health approaches to improve safe anticoagulant use in the outpatient setting: the DOAC Dashboard multi-cohort implementation evaluation study protocol

“…The research team will interview anticoagulation clinic managers about specific implementation strategies employed and operational details about use of the Dashboard. Ongoing data collection through the MAQI 2 consortium will be utilized to assess implementation success [32].…”