Bridging Evidence-Based Practice and Practice-Based Evidence in Periprocedural Anticoagulation

Abstract

More than 2 million people are currently treated with oral anticoagulation in North America alone.1 Indeed, chronically anticoagulated patients are expected to become more prevalent as the population ages and the incidence of conditions (for example, atrial fibrillation) requiring anticoagulation increases.2 Article see p 1630 Many of these patients may undergo an invasive or operative procedure at some point, and thus their periprocedural management will be a commonly encountered problem. The challenge in periprocedural management of anticoagulated patients focuses on the need to balance risk of thromboembolism (in case of anticoagulation interruption) against the risk of bleeding during the procedure (in case of anticoagulation continuation). Thus, a crucial first step in the management of such patients is estimation of periprocedural bleeding and thrombotic risk, and balancing both. In certain chronic conditions, such as AF, risk stratification scores assist decision making when risk of thrombosis and bleeding needs to be weighed.3–5 However, when an invasive procedure is involved, thrombosis and bleeding scores have been less well validated, and the optimal management of anticoagulated patients remains controversial. For many years, bridging therapy has been practiced when considering an interventional procedure, and anticoagulation was continued with parenteral heparins whenever the vitamin K antagonists (eg, warfarin) had to be interrupted (Figure).6–8 The rationale of a bridging strategy was to replace coumadins by a parenteral agent with short half-life and rapid onset of action that can be discontinued only a few hours before and commenced a few hours after the procedure.8 However, some argue that this empirical approach lacks robust evidence, and therefore this approach has been subject to some debate.9,10 When considering the balance between risk and benefit, supporters of bridging therapy allege low rates of bleeding complications as the reason …