Abstract
The risk and benefit of periprocedural heparin bridging is not completely clarified. We aimed to assess the safety and efficacy of bridging anticoagulation prior to invasive procedures or surgery. Heparin bridging was associated with lower risks of thromboembolism and bleeding compared to non‐bridging. PubMed, Ovid and Elsevier, and Cochrane Library (2000‐2016) were searched for English‐language studies. Studies comparing interrupted anticoagulation with or without bridging and continuous oral anticoagulation in patients at moderate‐to‐high thromboembolic risk before invasive procedures were included. Primary outcomes were thromboembolic events and bleeding events. Mantel‐Haenszel method and random‐effects models were used to analyze the pooled risk ratio (RR) and 95% confidence interval (CI) for thromboembolic and bleeding risks. Eighteen studies (six randomized controlled trials and 12 cohort studies) were included (N = 23 364). There was no difference in thromboembolic risk between bridged and non‐bridged patients (RR: 1.26, 95% CI: 0.61‐2.58; RCTs: RR: 0.71, 95% CI: 0.23‐2.24; cohorts: RR: 1.45, 95% CI: 0.63‐3.37). However, bridging anticoagulation was associated with higher risk of overall bleeding (RR: 2.83, 95% CI: 2.00‐4.01; RCTs: RR: 2.24, 95% CI: 0.99‐5.09; cohorts: RR: 3.09, 95% CI: 2.07‐4.62) and major bleeding (RR: 3.00, 95% CI: 1.78‐5.06; RCTs: RR: 2.48, 95% CI: 1.29‐4.76; cohorts: RR: 3.22, 95% CI: 1.65‐6.32). Bridging anticoagulation was associated with increased bleeding risk compared to non‐bridging. Thromboembolism risk was similar between two strategies. Our results do not support routine use of bridging during anticoagulation interruption.
Highlights
An estimated 2.5 million patients use oral anticoagulants for the prevention of arterial thromboembolic events in North America, and onetenth of them require temporary interruption in preparation for an elective procedure or surgery.[1,2] the safety and efficacy of bridging anticoagulation is not completely clarified for patients who need an anticoagulation interruption before invasive procedures
Before invasive procedures or surgery, LMWH was discontinued within 24 hours in 19% of studies, beyond 24 hours in 44% of studies, and at unspecified time in 37% of studies
The analysis showed a higher risk of major bleeding associated with bridging anticoagulation compared to non-bridging strategy with a high level of heterogeneity, risk ratio (RR): 3.00
Summary
An estimated 2.5 million patients use oral anticoagulants for the prevention of arterial thromboembolic events in North America, and onetenth of them require temporary interruption in preparation for an elective procedure or surgery.[1,2] the safety and efficacy of bridging anticoagulation is not completely clarified for patients who need an anticoagulation interruption before invasive procedures. An estimated 2.5 million patients use oral anticoagulants for the prevention of arterial thromboembolic events in North America, and onetenth of them require temporary interruption in preparation for an elective procedure or surgery.[1,2]. The safety and efficacy of bridging anticoagulation is not completely clarified for patients who need an anticoagulation interruption before invasive procedures. To reduce the bleeding risk for patients undergoing invasive procedures, oral anticoagulant is typically interrupted prior to the procedure, and continued when hemostasis is achieved postprocedurally.[1,2]. Because the interruption of anticoagulation may expose patients to the risk of thromboembolism, heparin bridging (unfractionated heparin [UFH] or low-molecular-weight heparin [LMWH]) is administered to minimize the period of inadequate level of anticoagulation.[1,2]. It is of great importance to confirm whether bridging therapy reduces thromboembolic risk and to ascertain the safety of bridging therapy in relation to bleeding risk.[3] To reduce the bleeding risk for patients undergoing invasive procedures, oral anticoagulant is typically interrupted prior to the procedure, and continued when hemostasis is achieved postprocedurally.[1,2] Because the interruption of anticoagulation may expose patients to the risk of thromboembolism, heparin bridging (unfractionated heparin [UFH] or low-molecular-weight heparin [LMWH]) is administered to minimize the period of inadequate level of anticoagulation.[1,2] It is of great importance to confirm whether bridging therapy reduces thromboembolic risk and to ascertain the safety of bridging therapy in relation to bleeding risk.[3]
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