Abstract
BackgroundPerioperative bridging in atrial fibrillation (AF) is associated with low thromboembolic rates but high bleeding rates. Recent guidance cautions the practice of bridging except in high risk patients. However, the practice of bridging varies widely and little data exist regarding appropriate anticoagulation intensity when using intravenous unfractionated heparin (UFH).HypothesisTo determine if high intensity UFH infusion regimens are associated with increased bleeding rates compared to low intensity regimens for bridging patients with AF.MethodsWe conducted a single center retrospective cohort study of admitted patients with non‐valvular AF receiving UFH for ≥24 hours. UFH intensities were chosen at the providers' discretion. The primary endpoint was the rate of bleeding defined by the International Society on Thrombosis and Hemostasis during UFH infusion or within 24 hours of discontinuation. The secondary endpoint was a composite of cardiovascular events, arterial thromboembolism, venous thromboembolism, myocardial infarctions and death during UFH infusion.ResultsA total of 497 patients were included in this analysis. Warfarin was used in 82.1% and direct acting oral anticoagulants in 14.1% of patients. The rate of any bleed was higher among high intensity compared to low intensity UFH regimens (10.5% vs 4.9%, odds ratio = 2.29, 95% confidence interval = 1.07‐4.90). Major bleeding was significantly higher among high intensity compared to low intensity UFH regimens. There was no difference in composite thrombotic events or death.ConclusionsLow intensity UFH infusions, targeting lower anticoagulation targets, were associated with decreased bleeding rates without a signal of increased thromboembolic events in hospitalized AF patients.
Highlights
Patients with atrial fibrillation (AF) have a 4- to 5-fold increased risk of ischemic stroke compared to patients in sinus rhythm.[1]
Current guidelines and expert consensus support perioperative bridging with subcutaneous low molecular weight heparin or intravenous unfractionated heparin (UFH) for patients taking oral vitamin K antagonists who are at high risk for thromboembolism, indicated by a CHA2DS2-VASc score greater than 5 to 6 or a prior thromboembolic event.[8,9,10,11,12,13,14]
It is well established that bleeding occurs at a much higher rate than thromboembolism in patients who receive perioperative bridging, at an approximate bleed to thrombosis ratio of 13:1 with a marked increase in the risk of bleeding (OR = 3.6, 95% CI = 1.52-8.50).[17]
Summary
Patients with atrial fibrillation (AF) have a 4- to 5-fold increased risk of ischemic stroke compared to patients in sinus rhythm.[1]. Studies have shown that perioperative bridging in AF is associated with a 4-fold risk of bleeding compared to non-bridging strategies (any bleed rates: 5%-34% and major bleed rates: 3%-9%) with undifferentiated thromboembolic events (0%-4%).[3,4,5,6,7] Current guidelines and expert consensus support perioperative bridging with subcutaneous low molecular weight heparin or intravenous unfractionated heparin (UFH) for patients taking oral vitamin K antagonists who are at high risk for thromboembolism, indicated by a CHA2DS2-VASc score greater than 5 to 6 or a prior thromboembolic event.[8,9,10,11,12,13,14] there is currently limited data and differing consensus within guidelines and literature regarding UFH dosing intensity for bridging in AF. Hypothesis: To determine if high intensity UFH infusion regimens are associated with increased bleeding rates compared to low intensity regimens for bridging patients with AF. Conclusions: Low intensity UFH infusions, targeting lower anticoagulation targets, were associated with decreased bleeding rates without a signal of increased thromboembolic events in hospitalized AF patients
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