Periprocedural Heparin Bridging in Patients Receiving Vitamin K Antagonists

Abstract

Background-Periprocedural bridging with unfractionated heparin or low-molecular-weight heparin aims to reduce the risk of thromboembolic events in patients receiving long-term vitamin K antagonists. Optimal periprocedural anticoagulation has not been established. Methods and Results-MEDLINE, EMBASE, and Cochrane databases (2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010) were searched for English-language studies including patients receiving heparin bridging during interruption of vitamin K antagonists for elective procedures. Data were independently collected by 2 investigators (ϭ0.90). The final review included 34 studies with 1 randomized trial. Thromboembolic events occurred in 73 of 7118 bridged patients (pooled incidence, 0.9%; 95% confidence interval [CI], 0.0.0 -3.4) and 32 of 5160 nonbridged patients (pooled incidence, 0.6%; 95% CI, 0.0 -1.2). There was no difference in the risk of thromboembolic events in 8 studies comparing bridged and nonbridged groups (odds ratio, 0.80; 95% CI, 0.42-1.54). Bridging was associated with an increased risk of overall bleeding in 13 studies (odds ratio, 5.40; 95% CI, 3.00 -9.74) and major bleeding in 5 studies (odds ratio, 3.60; 95% CI, 1.52-8.50) comparing bridged and nonbridged patients. There was no difference in thromboembolic events (odds ratio, 0.30; 95% CI, 0.04 -2.09) but an increased risk of overall bleeding (odds ratio, 2.28; 95% CI, 1.27-4.08) with full versus prophylactic/intermediate-dose low-molecular-weight heparin bridging. Low-thromboembolic-risk and/or non-vitamin K antagonist patient groups were used for comparison. Study quality was poor with heterogeneity for some analyses. Conclusions-Vitamin K antagonist-treated patients receiving periprocedural heparin bridging appear to be at increased risk of overall and major bleeding and at similar risk of thromboembolic events compared to nonbridged patients. Randomized trials are needed to define the role of periprocedural heparin bridging. (Circulation. 2012;126:1630-1639.)Key Words: anticoagulants Ⅲ bridging Ⅲ heparin Ⅲ periprocedural Ⅲ thromboembolism Ⅲ warfarin V itamin K antagonists (VKAs) such as warfarin are commonly used long term for the prevention of arterial thromboembolic events such as stroke and systemic embolism in patients with atrial fibrillation or mechanical heart valves and recurrent venous thromboembolic events. Approximately 10% of patients receiving long-term warfarin may require interruption of therapy for invasive procedures or surgery, and it is estimated that Ͼ250 000 patients on long-term warfarin undergo periprocedural assessment in North America each year. 1 There is concern that periprocedural interruption of warfarin may increase the risk of thromboembolic events, whereas continuation of warfarin in the periprocedural period will increase the risk of bleeding. 2 Periprocedural bridging anticoagulation with short-acting parenteral agents such as unfractionated heparin or lowmolecular-weight heparin (LMWH) has been increasingly used in the past decade with the aim ...

Perioperative anticoagulation in device implantation: Benefitting the uninterrupted

“…This metaanalysis is also consistent with another recent meta-analysis by Siegal et al (13). The data supports a strategy that is clinically meaningful with regard to safety as well as convenient for both patients and treating physicians (14).…”

Safety and Efficacy of Bridging With Low-Molecular-Weight Heparin During Temporary Interruptions of Warfarin: A Register-Based Cohort Study

“…1 Well-made studies of bridging showing positive benefit/risk ratio are scarce, with many studies comparing LMWH to unfractionated heparin instead of placebo or no treatment. 2 Guidelines are mainly based on meta-analyses. 3 Studies on recurrence of venous thromboembolism 4 and arterial thromboembolism from atrial fibrillation 5 were not in favor of LMWH bridging.…”

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

“…Recently, several studies have examined the risks of bleeding and of ischemic stroke and systemic embolism (IS/SE) associated with perioperative heparin bridging anticoagulation in patients with NVAF 3, 4, 5, 6. However, no studies have investigated bridging risks during VKA initiation in outpatient settings.…”