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Navin PJ, Eickstaedt NL, Atwell TD, Young JR, Eiken PW, Welch BT, Schmitz JJ, Schmit GD, Johnson MP, Moynagh MR. Safety and Efficacy of Percutaneous Image-Guided Mediastinal Mass Core-Needle Biopsy. Mayo Clin Proc Innov Qual Outcomes 2021; 5:1100-1108. [PMID: 34877475 PMCID: PMC8633817 DOI: 10.1016/j.mayocpiqo.2021.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objective To retrospectively evaluate the safety and efficacy of percutaneous image-guided mediastinal mass core-needle biopsy. Patients and Methods Retrospective review of an institutionally maintained biopsy registry identified 337 computed tomography- or ultrasound-guided percutaneous mediastinal mass core needle biopsies between October 2002 and August 2017 in a single quaternary referral center. Mean patient age was 51 (range, 18 to 93) years. Procedural techniques, anticoagulation/antiplatelet therapy, and tumor anatomical characteristics were reviewed. Classification and gradation of complications was based on the Clavien-Dindo system. Diagnostic yield was defined as the ratio of diagnostic biopsy to all biopsies performed. Results Mean tumor size was 59.2 (range, 10 to 180) mm with 89.9% (n=303) of lesions located in the prevascular (anterior) mediastinum. There was a single major complication (0.3%) of a symptomatic pneumothorax requiring intervention. There were seven (2.1%) minor complications, including three bleeding complications. A transpleural approach was the only variable associated with an increased complication rate (P<.01). Forty-one (12.2%) patients had a biopsy performed while taking an antiplatelet/anticoagulant agent within the therapeutic window, with a single case (0.3%) associated with a minor bleeding complication. Of 18 (5.3%) procedures performed without cessation of anticoagulant/antiplatelet therapy, there were no bleeding complications. Of all 337 biopsies, 322 (95.5%) were diagnostic. None of the analyzed variables were significantly associated with a nondiagnostic biopsy. Conclusion Image-guided percutaneous core-needle biopsy of mediastinal masses is a safe procedure with high diagnostic yield. Further prospective studies are required to assess the complication profile in higher risk patients.
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Siddiqui MU, Pasha AK, Rauf I, Lee JZ, Siddiqui MD, Yaacoub Y, Movahed MR. Efficacy and Safety of Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation Undergoing Elective Surgical Procedures: A Meta-analysis. Clin Med Res 2021; 19:19-25. [PMID: 33060109 PMCID: PMC7987095 DOI: 10.3121/cmr.2020.1546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/26/2020] [Accepted: 09/11/2020] [Indexed: 01/15/2023]
Abstract
Objective: The study objective was to determine if peri-operative bridging anticoagulation in patients with atrial fibrillation is beneficial or harmful.Design: Systematic review and meta-analysis.Setting: Inpatient or in-hospital setting.Participants: Adults with atrial fibrillation having a CHADS2 score >1 undergoing elective surgical procedure on anticoagulation.Methods: A systemic search of multiple databases (Cochrane, Medline, PubMed) was performed regarding studies conducted on efficacy and safety of perioperative bridging anticoagulation in patients with atrial fibrillation. Studies identified were reviewed by two authors individually before inclusion. The results were then pooled using Review Manager to determine the combined effect. Stroke/systemic embolism was considered as the primary efficacy outcome. Major bleeding was the primary safety outcome.Results: The systematic search revealed 108 potential articles. The full texts of 28 articles were retrieved for assessment of eligibility. After full text review, 25 articles were excluded. Three articles met inclusion criteria. No significant difference in stroke/systemic embolism with bridging anticoagulation was noted (risk ratio, 1.25-95% confidence interval [CI], 0.55-2.85). Bridging was associated with significantly higher risk of major bleeding (risk ratio, 3.29-95% CI, 2.25-4.81).Conclusion: An individualized approach is required when initiating peri-operative bridging anticoagulation. There is certainly a higher risk of bleeding with bridging anticoagulation and no difference in stroke/systemic embolism. However, the results cannot be extrapolated to patients who have valvular atrial fibrillation or CHADS2 score of 5 or greater.
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Affiliation(s)
- Muhammad Umer Siddiqui
- Marshfield Clinic Health System, Eau Claire, Wisconsin, USA [Current affiliation: George Washington University, Washington, DC, USA
| | - Ahmed K Pasha
- Mayo Clinic Health System, Rochester, Minnesota, USA
| | - Ibtisam Rauf
- Northwestern University Feinberg School of Medicine, Department of Physical Therapy and Human Movement, Chicago, Illinois, USA
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Park BE, Bae MH, Kim HJ, Park YJ, Kim HN, Jang SY, Lee JH, Yang DH, Park HS, Cho Y, Chae SC. Perioperative outcomes of interrupted anticoagulation in patients with non-valvular atrial fibrillation undergoing non-cardiac surgery. Yeungnam Univ J Med 2020; 37:321-328. [PMID: 32668522 PMCID: PMC7606955 DOI: 10.12701/yujm.2020.00353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/17/2020] [Indexed: 12/21/2022] Open
Abstract
Background This study aimed to investigate the incidences of and risk factors for perioperative events following anticoagulant discontinuation in patients with non-valvular atrial fibrillation (NVAF) undergoing non-cardiac surgery. Methods A total of 216 consecutive patients who underwent cardiac consultation for suspending perioperative anticoagulants were enrolled. A perioperative event was defined as a composite of thromboembolism and major bleeding. Results The mean anticoagulant discontinuation duration was 5.7 (±4.2) days and was significantly longer in the warfarin group (p<0.001). Four perioperative thromboembolic (1.9%; three strokes and one systemic embolization) and three major bleeding events (1.4%) were observed. The high CHA2DS2-VASc and HAS-BLED scores and a prolonged preoperative anticoagulant discontinuation duration (4.4±2.1 vs. 2.9±1.8 days; p=0.028) were associated with perioperative events, whereas the anticoagulant type (non-vitamin K antagonist oral anticoagulants or warfarin) was not. The best cut-off levels of the HAS-BLED and CHA2DS2-VASc scores were 3.5 and 2.5, respectively, and the preoperative anticoagulant discontinuation duration for predicting perioperative events was 2.5 days. Significant differences in the perioperative event rates were observed among the four risk groups categorized according to the sum of these values: risk 0, 0%; risk 1, 0%; risk 2, 5.9%; and risk 3, 50.0% (p<0.001). Multivariate logistic regression analysis showed that the HAS-BLED score was an independent predictor for perioperative events. Conclusion Thromboembolic events and major bleeding are not uncommon during perioperative anticoagulant discontinuation in patients with NVAF, and interrupted anticoagulation strategies are needed to minimize these.
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Affiliation(s)
- Bo Eun Park
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Myung Hwan Bae
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyeon Jeong Kim
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yoon Jung Park
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hong Nyun Kim
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Se Yong Jang
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jang Hoon Lee
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong Heon Yang
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hun Sik Park
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yongkeun Cho
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Shung Chull Chae
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Kuo HC, Liu FL, Chen JT, Cherng YG, Tam KW, Tai YH. Thromboembolic and bleeding risk of periprocedural bridging anticoagulation: A systematic review and meta-analysis. Clin Cardiol 2020; 43:441-449. [PMID: 31944351 PMCID: PMC7244304 DOI: 10.1002/clc.23336] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 12/26/2022] Open
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.
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Affiliation(s)
- Hsien-Cheng Kuo
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Feng-Lin Liu
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jui-Tai Chen
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yih-Giun Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Ying-Hsuan Tai
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance. Thromb J 2019; 17:15. [PMID: 31391790 PMCID: PMC6681479 DOI: 10.1186/s12959-019-0204-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/26/2019] [Indexed: 12/18/2022] Open
Abstract
Background Bridging anticoagulation is used in vitamin-K antagonist (VKA) patients undergoing invasive procedures and involves complex risk assessment in order to prevent thromboembolic and bleeding outcomes. Objectives Our aim was to assess guideline compliance and identify factors associated with bridging and especially, non-compliant bridging. Methods A retrospective review of 256 patient records in 13 Dutch hospitals was performed. Demographic, clinical, surgical and care delivery characteristics were collected. Compliance to the American College of Chest Physicians ninth edition guideline (AT9) was assessed. Multilevel regression models were built to explain bridging use and predict non-compliance. Results Bridging use varied from 15.0 to 83.3% (mean = 41.8%) of patients per hospital, whereas guideline compliance varied from 20.0 to 88.2% (mean = 68.5%) per hospital. Both established thromboembolic risk factors and characteristics outside thromboembolic risk assessment were associated with bridging use. Predictors for overuse were gastrointestinal surgery (OR 14.85, 95% CI 2.69-81.99), vascular surgery (OR 13.01, 95% CI 1.83-92.30), non-elective surgery (OR 8.67, 95% CI 1.67-45.14), lowest 25th percentile socioeconomic status (OR 0.33, 95% CI 0.11-1.02) and use of VKA reversal agents (OR 0.22, 95% CI 0.04-1.16). Conclusion Bridging anticoagulation practice was not compliant with the AT9 in 31.5% of patients. The aggregated AT9 thromboembolic risk was inferior to individual thromboembolic risk factors and other characteristics in explaining bridging use. Therefor the AT9 risk seems less important for the decision making in everyday practice. Additionally, a heterogeneous implementation of the guideline between hospitals was found. Further research and interventions are needed to improve bridging anticoagulation practice in VKA patients.
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Anticoagulation Use prior to Common Dental Procedures: A Systematic Review. Cardiol Res Pract 2019; 2019:9308631. [PMID: 31275643 PMCID: PMC6589257 DOI: 10.1155/2019/9308631] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 04/28/2019] [Accepted: 05/09/2019] [Indexed: 11/27/2022] Open
Abstract
Currently, the number of patients on oral anticoagulation is increasing. There is a paucity of data regarding maintaining oral anticoagulation (especially novel oral anticoagulants) around the time of specific dental procedures. A dentist has three options: either to stop anticoagulation, to continue it, or to bridge with heparin. A systematic review of 10 clinical trials was conducted to address this issue. It was found that continuing anticoagulation during dental procedures did not increase the risk of bleeding in most trials. Although none of the studies reported a thromboembolic event after interruption of anticoagulation, the follow-up periods were short and inconsistent, and the heightened thromboembolic risk when stopping anticoagulation is well known in the literature. Heparin bridging was associated with an increased bleeding incidence. We recommend maintaining oral anticoagulation with vitamin K antagonists and novel oral anticoagulants for the vast majority of dental procedures along with the use of local hemostatic agents.
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7
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Slivnick JA, Yeow RY, McMahon C, Paje DG, Kurlander JE, Barnes GD. Current Trends in Anticoagulation Bridging for Patients With Chronic Atrial Fibrillation on Warfarin Undergoing Endoscopy. Am J Cardiol 2018; 121:1548-1551. [PMID: 29678338 DOI: 10.1016/j.amjcard.2018.02.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 02/19/2018] [Accepted: 02/26/2018] [Indexed: 11/29/2022]
Abstract
For warfarin-treated patients with atrial fibrillation (AF) at low thromboembolic risk, recent studies have shown harm associated with periprocedural bridging using low-molecular-weight heparin. Clinician surveys have indicated a preference toward excessive bridging, especially among noncardiologists; however, little is known about actual practice patterns in these patients. We performed a retrospective evaluation of bridging in the setting of gastrointestinal endoscopy. We identified 938 patients with AF on warfarin who underwent esophagogastroduodenoscopy or colonoscopy between 2012 and 2016 at a tertiary health center. Urgent, inpatient, or advanced endoscopic procedures were excluded. Clinical variables were abstracted using a predefined data dictionary. Values were expressed as means and compared using a t test or a chi-squared test as appropriate. Three hundred seventy-four patients met criteria for analysis. Twenty-five percent of these patients received bridging therapy, including 11% of patients with CHADS2 scores of 0 to 2 without valvular AF or previous venous thromboembolism. Of the clinical variables assessed, CHADS2, CHA2DS2-VASc, and a history of stroke were the strongest predictors of bridging. Cardiologists were also significantly less likely to prescribe bridging than noncardiology providers (18% vs 30%, p = 0.011); this effect was significant when controlling for CHADS2, CHA2DS2-VASc, or stroke history. In conclusion, patients with AF on warfarin receive excessive low-molecular-weight heparin bridging in the setting of endoscopy; the lower rates of bridging observed among cardiologists suggests a need for their increased involvement in this decision making.
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8
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Hovaguimian F, Köppel S, Spahn DR. Safety of Anticoagulation Interruption in Patients Undergoing Surgery or Invasive Procedures: A Systematic Review and Meta-analyses of Randomized Controlled Trials and Non-randomized Studies. World J Surg 2018; 41:2444-2456. [PMID: 28608011 DOI: 10.1007/s00268-017-4072-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The safety of anticoagulation interruption in patients requiring surgical or invasive procedures remains unclear. We thus performed a systematic review and meta-analyses of randomized controlled trials (RCTs) and non-randomized studies (NRS). METHODS MEDLINE, Embase and Central databases were searched to March 2017 without date or language restrictions. We considered RCTs and NRS comparing anticoagulation interruption with any anticoagulation (continuation or heparin bridging) in adult surgical patients taking oral anticoagulation. Data were independently extracted. The quality of the evidence was assessed following recommendations from the Cochrane collaboration (GRADE approach). Risk ratios were calculated for 30-day events: thromboembolic (TE) events, major bleeding and mortality. Additional analyses explored the effects of different anticoagulation strategies. RESULTS Twelve reports were included: 4 RCTs (2190 participants) and 8 NRS (18993 participants). Trials included mostly participants with atrial fibrillation. Interrupting anticoagulation did not seem to increase TE events (RR 0.65, 95% CI [0.33, 1.30]-4 studies, 2190 participants) and resulted in less bleeding (RR 0.41, 95% CI [0.22, 0.78]-3 studies, 2126 participants) compared to anticoagulation continuation or heparin bridging. The GRADE assessment was moderate. Similar results were found in non-randomized studies, but the quality of the evidence was low. Possible strategy-specific effects were identified: forgoing heparin bridging seemed beneficial, but these effects were less clear with other strategies. CONCLUSION Interrupting anticoagulation in patients requiring invasive procedures did not seem to result in harm and protected against major bleeding. Uncertainty remains regarding the safety of this strategy in indications other than atrial fibrillation and in moderate- to high-risk surgery. STUDY REGISTRATION http://www.en.anaesthesie.usz.ch/research/Pages/Study-protocols.aspx.
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Affiliation(s)
- Frédérique Hovaguimian
- Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, 8091, Zurich, Switzerland.
| | - Sabrina Köppel
- Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, 8091, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, 8091, Zurich, Switzerland
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Yong JW, Yang LX, Ohene BE, Zhou YJ, Wang ZJ. Periprocedural heparin bridging in patients receiving oral anticoagulation: a systematic review and meta-analysis. BMC Cardiovasc Disord 2017; 17:295. [PMID: 29237411 PMCID: PMC5729256 DOI: 10.1186/s12872-017-0719-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 11/24/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Periprocedural heparin bridging therapy aims to reduce the risk of thromboembolic events in patients requiring an interruption in their anticoagulation therapy for the purpose of an elective procedure. The efficacy and safety of heparin bridging therapy has not been well established. OBJECTIVES To compare through meta-analysis the effects of heparin bridging therapy on the risk of major bleeding and thromboembolic events of clinical significance among patients taking oral anticoagulants. METHODS We searched PubMed, EMBASE and the Cochrane library from January 2005 to July 2016. Studies were included if they reported clinical outcomes of patients receiving heparin bridging therapy during interruption of oral anticoagulant for operations. Data were pooled using random-effects modeling. RESULTS A total of 25 studies, including 6 randomized controlled trials and 19 observational studies, were finally included in this analysis. Among all the 35,944 patients, 10,313 patients were assigned as heparin bridging group, and the other 25,631 patients were non-heparin bridging group. Overall, compared with patients without bridging therapy, heparin bridging therapy increased the risk of major bleeding (OR = 3.23, 95%CI: 2.06-5.05), minor bleeding (OR = 1.52, 95%CI: 1.06-2.18) and overall bleeding (OR = 2.83, 95%CI: 1.86-4.30).While there was no significant difference in thromboembolic events (OR = 0.99,95%CI: 0.49-2.00), stroke or transient ischemic attack(OR = 1.45, 95%CI: 0.93-2.26,) or all-cause mortality (OR = 0.71, 95%CI: 0.31-1.65). CONCLUSIONS Heparin-bridging therapy increased the risk of major and minor bleeding without decreasing the risk of thromboembolic events and all cause death compared to non-heparin bridging.
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Affiliation(s)
- Jing Wen Yong
- Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Li Xia Yang
- Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bright Eric Ohene
- Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yu Jie Zhou
- Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhi Jian Wang
- Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Anzhen Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Avenue #2, Chaoyang district, Beijing, 100029 China
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Abstract
In patients with atrial fibrillation (AF), oral anticoagulation is used to prevent stroke and systemic embolism. In a common clinical scenario, AF patients frequently undergo invasive procedures requiring temporary interruption of oral anticoagulation, thereby potentially exposing such patients to increased risk of thromboembolism. Bridging anticoagulation has been used clinically to mitigate this perceived thromboembolic risk, though this practice may also increase risk of periprocedural bleeding. High-quality data has not previously existed to inform decision-making in this clinical situation of bridging anticoagulation. We discuss recent results from the BRIDGE trial and secondary analyses from recent phase 3 randomized clinical trials of direct-acting oral anticoagulant (DOAC) use in non-valvular AF, that inform periprocedural anticoagulation with bridging strategies in AF patients. Updated data from these current trials favor against a strategy of bridging anticoagulation for elective procedures in the majority of AF patients, low or moderate in thromboembolic risk. Bridging anticoagulation is associated with an increased risk of bleeding and no decreased risk of thromboembolism.
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11
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Warner NS, Moeschler SM, Eldrige JS. Regarding the Safety of Interventional Pain Procedures in the Setting of Anticoagulation. PAIN MEDICINE 2017; 18:819-820. [PMID: 28034976 DOI: 10.1093/pm/pnw253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Nafisseh S Warner
- Division of Pain Medicine and Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Susan M Moeschler
- Division of Pain Medicine and Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason S Eldrige
- Division of Pain Medicine and Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
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Hamano I, Hatakeyama S, Yoneyama T, Tobisawa Y, Soma O, Matsumoto T, Yamamoto H, Imai A, Yoneyama T, Hashimoto Y, Koie T, Ohyama C. Safety of heparin bridging therapy for transrectal ultrasound-guided prostate biopsy in patients requiring temporary discontinuation of antithrombotic agents. SPRINGERPLUS 2016; 5:1917. [PMID: 27867824 PMCID: PMC5097055 DOI: 10.1186/s40064-016-3610-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 10/27/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Safety of heparin bridging therapy for transrectal ultrasound-guided prostate (TRUS) biopsy in patients requiring temporary discontinuation of antithrombotic therapy is unknown. This study aimed to assess the relationship between heparin bridging therapy and the incidence of complications after TRUS biopsy. METHODS From January 2005 to November 2015, we performed 1307 consecutive TRUS biopsies on 1134 patients in our hospital. The patients were assigned to two groups: those without heparin bridging (the control group) and those with temporary discontinuation of antithrombotic agents with heparin bridging therapy (the bridging group). A 10-12-core TRUS biopsy was performed; the patients were evaluated for bleeding-related complications. RESULTS Of 1134 patients, 1109 (1281 biopsies) and 25 (26 biopsies) were assigned to the control and bridging group, respectively. Patient background did not significantly differ between the control and bridging groups, except for age, history of diabetes, cardiovascular diseases, and CHADS2 scores. Compared with the control group, the bridging group showed a significantly higher rate of complication for any complication (35 vs. 8.3%, P < 0.001), bleeding-related complications (27 vs. 4.4%), and urinary tract infection (7.7 vs. 1.2%). No thromboembolic event was observed in the present study. Multivariate logistic analysis showed that heparin bridging therapy was a significant risk factor for the incidence of any complication and bleeding-related complications. CONCLUSIONS Heparin bridging therapy with temporal discontinuation of antithrombotic agents may increase the risk of complications after TRUS biopsy. Further, large-scale studies are required to clarify the safety of heparin bridging therapy.
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Affiliation(s)
- Itsuto Hamano
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562 Japan
| | - Shingo Hatakeyama
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562 Japan
| | - Tohru Yoneyama
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuki Tobisawa
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562 Japan
| | - Osamu Soma
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562 Japan
| | - Teppei Matsumoto
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562 Japan
| | - Hayato Yamamoto
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562 Japan
| | - Atsushi Imai
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takahiro Yoneyama
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuhiro Hashimoto
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takuya Koie
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562 Japan
| | - Chikara Ohyama
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562 Japan ; Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Wight JM, Columb MO. Perioperative bridging anticoagulation for atrial fibrillation-the first randomised controlled trial. Perioper Med (Lond) 2016; 5:14. [PMID: 27280017 PMCID: PMC4897904 DOI: 10.1186/s13741-016-0040-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/23/2016] [Indexed: 12/31/2022] Open
Abstract
Abstract Patients who have atrial fibrillation (AF) have increased thromboembolic risk. This risk is mitigated through use of anticoagulants, traditionally with vitamin K antagonists such as warfarin, and more recently with drugs such as Xa and thrombin inhibitors. Since anticoagulants increase the risk of bleeding, uncertainty exists regarding their use in the perioperative period. The risk of thromboembolism for each patient must be balanced against risk of bleeding; anticoagulation medication may be continued, replaced with a short-acting alternative or withheld entirely. Until recently, evidence on best management relied on expert opinion and observational studies. The recent publication of a randomised, double-blind, placebo-controlled trial (BRIDGE) has added important information to the knowledge base. Trial registration BRIDGE ClinicalTrials.gov, NCT00786474
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Affiliation(s)
- James Matthew Wight
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - Malachy Oliver Columb
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of South Manchester, Wythenshawe, UK
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14
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Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, Garcia DA, Jacobson A, Jaffer AK, Kong DF, Schulman S, Turpie AGG, Hasselblad V, Ortel TL. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med 2015; 373:823-33. [PMID: 26095867 PMCID: PMC4931686 DOI: 10.1056/nejmoa1501035] [Citation(s) in RCA: 706] [Impact Index Per Article: 78.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding. METHODS We performed a randomized, double-blind, placebo-controlled trial in which, after perioperative interruption of warfarin therapy, patients were randomly assigned to receive bridging anticoagulation therapy with low-molecular-weight heparin (100 IU of dalteparin per kilogram of body weight) or matching placebo administered subcutaneously twice daily, from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. Warfarin treatment was stopped 5 days before the procedure and was resumed within 24 hours after the procedure. Follow-up of patients continued for 30 days after the procedure. The primary outcomes were arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding. RESULTS In total, 1884 patients were enrolled, with 950 assigned to receive no bridging therapy and 934 assigned to receive bridging therapy. The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (risk difference, 0.1 percentage points; 95% confidence interval [CI], -0.6 to 0.8; P=0.01 for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority). CONCLUSIONS In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health; BRIDGE ClinicalTrials.gov number, NCT00786474.).
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Affiliation(s)
- James D Douketis
- From St. Joseph's Healthcare Hamilton (J.D.D.) and the Department of Medicine (J.D.D.) and Hamilton Health Science Center (S.S., A.G.G.T.), McMaster University, Hamilton, ON, Canada; Hofstra North Shore-Long Island Jewish School of Medicine, Manhasset (A.C.S.), and Mount Sinai Medical Center, New York (A.S.D.) - both in New York; Hurley Medical Center, Flint, MI (S.K.); University of Cincinnati College of Medicine, Cincinnati (R.C.B.); NorthShore University HealthSystem, Evanston (J.A.C.), and Rush University Medical Center, Chicago (A.K.J.) - both in Illinois; University of Washington Medical Center, Seattle (D.A.G.); Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA (A.J.); and Duke Clinical Research Institute (D.F.K., V.H.) and Department of Medicine (T.L.O.), Duke University Medical Center, Durham, NC
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15
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Zaca V, Marcucci R, Parodi G, Limbruno U, Notarstefano P, Pieragnoli P, Di Cori A, Bongiorni MG, Casolo G. Management of antithrombotic therapy in patients undergoing electrophysiological device surgery. Europace 2015; 17:840-54. [DOI: 10.1093/europace/euu357] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/13/2014] [Indexed: 11/14/2022] Open
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Management and clinical outcomes in patients treated with apixaban vs warfarin undergoing procedures. Blood 2014; 124:3692-8. [PMID: 25320240 DOI: 10.1182/blood-2014-08-595496] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Using data from ARISTOTLE, we describe the periprocedural management of anticoagulation and rates of subsequent clinical outcomes among patients chronically anticoagulated with warfarin or apixaban. We recorded whether (and for how long) anticoagulant therapy was interrupted preprocedure, whether bridging therapy was used, and the proportion of patients who experienced important clinical outcomes during the 30 days postprocedure. Of 10 674 procedures performed during follow-up in 5924 patients, 9260 were included in this analysis. Anticoagulant treatment was not interrupted preprocedure 37.5% of the time. During the 30 days postprocedure, stroke or systemic embolism occurred after 16/4624 (0.35%) procedures among apixaban-treated patients and 26/4530 (0.57%) procedures among warfarin-treated patients (odds ratio [OR] 0.601; 95% confidence interval [CI] 0.322-1.120). Major bleeding occurred in 74/4560 (1.62%) procedures in the apixaban arm and 86/4454 (1.93%) in the warfarin arm (OR 0.846; 95% CI 0.614-1.166). The risk of death was similar with apixaban (54/4624 [1.17%]) and warfarin (49/4530 [1.08%]) (OR 1.082; 95% CI 0.733-1.598). Among patients in ARISTOTLE, the 30-day postprocedure stroke, death, and major bleeding rates were low and similar in apixaban- and warfarin-treated patients, regardless of whether anticoagulation was stopped beforehand. Our findings suggest that many patients on chronic anticoagulation can safely undergo procedures; some will not require a preprocedure interruption of anticoagulation. ARISTOTLE was registered at www.clinicaltrials.gov as #NCT00412984.
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Abstract
Atrial fibrillation increases the risk of stroke, which is a leading cause of death and disability worldwide. The use of oral anticoagulation in patients with atrial fibrillation at moderate or high risk of stroke, estimated by established criteria, improves outcomes. However, to ensure that the benefits exceed the risks of bleeding, appropriate patient selection is essential. Vitamin K antagonism has been the mainstay of treatment; however, newer drugs with novel mechanisms are also available. These novel oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) obviate many of warfarin's shortcomings, and they have demonstrated safety and efficacy in large randomized trials of patients with non-valvular atrial fibrillation. However, the management of patients taking warfarin or novel agents remains a clinical challenge. There are several important considerations when selecting anticoagulant therapy for patients with atrial fibrillation. This review will discuss the rationale for anticoagulation in patients with atrial fibrillation; risk stratification for treatment; available agents; the appropriate implementation of these agents; and additional, specific clinical considerations for treatment.
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Affiliation(s)
- Benjamin A Steinberg
- Electrophysiology Section, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA
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18
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Sherwood MW, Douketis JD, Patel MR, Piccini JP, Hellkamp AS, Lokhnygina Y, Spyropoulos AC, Hankey GJ, Singer DE, Nessel CC, Mahaffey KW, Fox KAA, Califf RM, Becker RC. Outcomes of temporary interruption of rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: results from the rivaroxaban once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation (ROCKET AF). Circulation 2014; 129:1850-9. [PMID: 24552831 DOI: 10.1161/circulationaha.113.005754] [Citation(s) in RCA: 201] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND During long-term anticoagulation in atrial fibrillation, temporary interruptions (TIs) of therapy are common, but the relationship between patient outcomes and TIs has not been well studied. We sought to determine reasons for TI, the characteristics of patients undergoing TI, and the relationship between anticoagulant and outcomes among patients with TI. METHODS AND RESULTS In the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF), a randomized, double-blind, double-dummy study of rivaroxaban and warfarin in nonvalvular atrial fibrillation, baseline characteristics, management, and outcomes, including stroke, non-central nervous system systemic embolism, death, myocardial infarction, and bleeding, were reported in participants who experienced TI (3-30 days) for any reason. The at-risk period for outcomes associated with TI was from TI start to 30 days after resumption of study drug. In 14 236 participants who received at least 1 dose of study drug, 4692 (33%) experienced TI. Participants with TI were similar to the overall ROCKET AF population in regard to baseline clinical characteristics. Only 6% (n=483) of TI incidences involved bridging therapy. Stroke/systemic embolism rates during the at-risk period were similar in rivaroxaban-treated and warfarin-treated participants (0.30% versus 0.41% per 30 days; hazard ratio [confidence interval]=0.74 [0.36-1.50]; P=0.40). Risk of major bleeding during the at-risk period was also similar in rivaroxaban-treated and warfarin-treated participants (0.99% versus 0.79% per 30 days; hazard ratio [confidence interval]=1.26 [0.80-2.00]; P=0.32). CONCLUSIONS TI of oral anticoagulation is common and is associated with substantial stroke risks and bleeding risks that were similar among patients treated with rivaroxaban or warfarin. Further investigation is needed to determine the optimal management strategy in patients with atrial fibrillation requiring TI of anticoagulation. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00403767.
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Affiliation(s)
- Matthew W Sherwood
- Division of Cardiovascular Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (M.W.S., M.R.P., J.P.P., A.S.H., Y.L., R.M.C., R.C.B.); Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, Hamilton, Ontario, Canada (J.D.D.); Department of Medicine, Division of Hematology, Hofstra North Shore/LIJ School of Medicine, Lenox Hill Hospital, New York, NY (A.C.S.); School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia (G.J.H.); Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); Johnson & Johnson Pharmaceutical Research and Development, Raritan, NJ (C.C.N.); Department of Medicine, Stanford University Medical Center, Palo Alto, CA (K.W.M.); and Department of Medicine, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
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Abstract
Perioperative management of antithrombotic therapy is a situation that occurs frequently and requires consideration of the patient, the procedure, and an expanding array of anticoagulant and antiplatelet agents. Preoperative assessment must address each patient's risk for thromboembolic events balanced against the risk for perioperative bleeding. Procedures can be separated into those with a low bleeding risk, which generally do not require complete reversal of the antithrombotic therapy, and those associated with an intermediate or high bleeding risk. For patients who are receiving warfarin who need interruption of the anticoagulant, consideration must be given to whether simply withholding the anticoagulant is the optimal approach or whether a perioperative "bridge" with an alternative agent, typically a low-molecular-weight heparin, should be used. The new oral anticoagulants dabigatran and rivaroxaban have shorter effective half-lives, but they introduce other concerns for perioperative management, including prolonged drug effect in patients with renal insufficiency, limited experience with clinical laboratory testing to confirm lack of residual anticoagulant effect, and lack of a reversal agent. Antiplatelet agents must also be considered in the perioperative setting, with particular consideration given to the potential risk for thrombotic complications in patients with coronary artery stents who have antiplatelet therapy withheld.
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20
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Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S-e350S. [PMID: 22315266 DOI: 10.1378/chest.11-2298] [Citation(s) in RCA: 1042] [Impact Index Per Article: 86.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. METHODS The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. RESULTS In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C). CONCLUSIONS Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael Mayr
- Medical Outpatient Department, University Hospital Basel, Basel, Switzerland
| | - Amir K Jaffer
- Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, OH
| | - Andrew S Dunn
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Regina Kunz
- Academy of Swiss Insurance Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland.
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Garwood CL, Hwang JM, Moser LR. Striking a balance between the risks and benefits of anticoagulation bridge therapy in patients with atrial fibrillation: clinical updates and remaining controversies. Pharmacotherapy 2012; 31:1208-20. [PMID: 22122182 DOI: 10.1592/phco.31.12.1208] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Long-term anticoagulation with a vitamin K antagonist (VKA) or the new agent dabigatran is recommended to decrease stroke risk in patients with atrial fibrillation. When patients with atrial fibrillation undergo initiation or interruption of VKA therapy, or experience an isolated subtherapeutic international normalized ratio (INR), bridge therapy with a parenteral anticoagulant may be considered. To describe the literature for anticoagulation bridge therapy in patients with atrial fibrillation, we conducted a MEDLINE search (1966-February 2011) of the English-language literature to identify related studies. Ongoing clinical trials were identified through a search of the ClinicalTrials.gov registry. Major national and international guidelines were gathered and evaluated. Additional literature was obtained through review of relevant references of the identified articles. Bridging is not supported by guidelines or clinical trials for patients starting VKA therapy for atrial fibrillation. A subtherapeutic INR value during long-term VKA therapy may be associated with increased thromboembolic events, but the benefit of bridging has not been demonstrated. When VKA therapy is interrupted for procedures, retrospective and cohort data suggest that the decision to bridge should be based on a patient's thromboembolic and bleeding risks associated with the procedure. Typically, it is recommended to use bridge therapy in patients with atrial fibrillation at high risk for thromboembolism, but the benefit of bridging is less clear in patients at low risk. Not all procedures necessitate anticoagulation interruption. Recent trials suggest that VKAs can be continued when patients are undergoing cardiac device procedures and some types of radiofrequency ablation. Several clinical trials are ongoing that will provide more definitive guidance for perioperative anticoagulation management of patients with atrial fibrillation. Patients taking dabigatran are unlikely to require bridge therapy because of a predictable anticoagulant effect and rapid onset of action. However, evidence for optimal perioperative management of dabigatran is needed.
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Affiliation(s)
- Candice L Garwood
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan 48201, USA.
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22
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Billett HH, Scorziello BA, Giannattasio ER, Cohen HW. Low molecular weight heparin bridging for atrial fibrillation: is VTE thromboprophylaxis the major benefit? J Thromb Thrombolysis 2011; 30:479-85. [PMID: 20405168 DOI: 10.1007/s11239-010-0470-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Paucity of data has led to a lack of consensus regarding indications for, and risk-benefit ratio of, low molecular weight heparin 'bridging' for cardioembolic prevention in patients with atrial fibrillation (AF) until their INR levels are in therapeutic range. Using a hospital database, we compared AF patients ≥65 years who were bridged (n = 265) with patients who were not bridged (n = 4532) after hospital discharge. Patients who failed to achieve a therapeutic INR within 30 days were excluded. CHADS₂ scores (congestive heart failure, hypertension, age ≥75, diabetes, stroke), bleeding risk and co-morbidity scores were assessed. Unadjusted and adjusted odds ratios for outcome events (death, stroke, hemorrhage and venous thromboembolism (VTE) within 30 days of discharge were compared. Bridged patients, as compared to those not bridged, were younger (74.7 ± 6.6 vs. 78.5 ± 7.7 years), less likely to be white (36 vs. 51%), and less likely to have CHADS₂ scores ≥2 (67 vs. 84%), all P < 0.001. There was no significant difference in bleeding risk (bridged vs. not bridged: 1.5 ± 7 vs. 1.7 ± 6). In logistic models adjusting for age, white race, bleeding risk, CHADS₂ and Comorbidity scores, bridging was significantly associated with lower mortality and a decreased odds ratio for VTE (both P < 0.01) but not for stroke or hemorrhage (both P > 0.80). Although we found insufficient evidence of either lower stroke or greater bleeding risk with bridging, our data suggest the possibility that LMWH bridging in patients with AF is associated with lower risks of VTE and death within 30 days of discharge.
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Affiliation(s)
- Henny H Billett
- Division of Hematology, Montefiore Medical Center, Albert Einstein College of Medicine, 3411 Wayne Ave., Bronx, NY 10467, USA.
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Kavanagh LE, Jack GS, Lawrentschuk N. Prevention and management of TURP-related hemorrhage. Nat Rev Urol 2011; 8:504-14. [PMID: 21844906 DOI: 10.1038/nrurol.2011.106] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Burbury KL, Milner A, Snooks B, Jupe D, Westerman DA. Short-term warfarin reversal for elective surgery - using low-dose intravenous vitamin K: safe, reliable and convenient*. Br J Haematol 2011; 154:626-34. [DOI: 10.1111/j.1365-2141.2011.08787.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Broderick JP, Bonomo JB, Kissela BM, Khoury JC, Moomaw CJ, Alwell K, Woo D, Flaherty ML, Khatri P, Adeoye O, Ferioli S, Kleindorfer DO. Withdrawal of antithrombotic agents and its impact on ischemic stroke occurrence. Stroke 2011; 42:2509-14. [PMID: 21719769 DOI: 10.1161/strokeaha.110.611905] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Antithrombotic medications (anticoagulants and antiplatelets) are often withheld in the periprocedural period and after bleeding complications to limit the risk of new or recurrent bleeding. These medications are also stopped by patients for various reasons such as cost, side effects, or unwillingness to take medication. METHODS Patient records from the population-based Greater Cincinnati/Northern Kentucky Stroke Study were reviewed to identify cases of ischemic stroke in 2005 and determine the temporal association of strokes with withdrawal of antithrombotic medication. Ischemic strokes and reasons for medication withdrawal were identified by study nurses for subsequent physician review. RESULTS In 2005, 2197 cases of ischemic stroke among residents of the region were identified through hospital discharge records. Of the 2197 ischemic strokes, 114 (5.2%) occurred within 60 days of an antithrombotic medication withdrawal, 61 (53.5%) of these after stoppage of warfarin and the remainder after stoppage of an antiplatelet medication. Of the strokes after withdrawal, 71 (62.3%) were first-ever and 43 (37.7%) were recurrent; 54 (47.4%) occurred after withdrawal of medication by a physician in the periprocedural period. CONCLUSIONS The withdrawal of antiplatelet and antithrombotic medications in the 60 days preceding an acute ischemic stroke was associated with 5.2% of ischemic strokes in our study population. This finding emphasizes the need for thoughtful decision-making concerning antithrombotic medication use in the periprocedural period and efforts to improve patient compliance.
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Affiliation(s)
- Joseph P Broderick
- University of Cincinnati, Department of Neurology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center MSB #0525, Cincinnati, OH 45242, USA.
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Postoperative hemorrhagic complications after elective laparoscopic cholecystectomy in patients receiving long-term anticoagulant therapy. Langenbecks Arch Surg 2009; 395:247-53. [PMID: 19294412 DOI: 10.1007/s00423-009-0483-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 03/02/2009] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS Among patients on long-term anticoagulant therapy who undergo laparoscopic cholecystectomy (LC), bleeding complications have not been extensively investigated. The objective of this study was therefore to investigate postoperative bleeding complications prospectively in patients on chronic oral anticoagulation. MATERIALS AND METHODS In the period of January 2002 to December 2007, 44 patients on long-term anticoagulation with warfarin, an oral anticoagulant (OAC), underwent LC in our center. Oral anticoagulant was discontinued 5 days before the planned date of surgery, and patients were admitted to the hospital 3 days before. Upon admission, bridging anticoagulation with enoxaparin, a low molecular weight heparin (LMWH), was started. When their international normalized ratio (INR) decreased to <1.5, patients underwent LC. In the absence of postoperative bleeding complications, OAC and LMWH were resumed on the evening of the day of surgery, and LMWH was continued until each patient's target INR was reached. A comparison group was comprised by 1,421 consecutively enrolled patients with no comorbid disease who underwent LC during the same period. RESULTS In the comparison group, postoperative bleeding was encountered in 21 patients (1.5%). In the anticoagulation group, postoperative bleeding was encountered in 11 patients (25%) and ranged from minor oozing from a port incision in one patient to hemorrhage, sepsis, and fatality in one patient. In the anticoagulation group, no significant differences were found between patients with and without postoperative bleeding in terms of age, gender, body mass index, American Society of Anesthesiologists score, INR, or other hemostasis parameters. CONCLUSIONS In patients who underwent LC with bridging anticoagulation, postoperative bleeding was markedly more frequent than expected and was not predicted by the usual coagulation parameters. This suggests a need for methods that can indicate which patients on long-term anticoagulation are at risk for postoperative bleeding.
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Kraai EP, Lopes RD, Alexander JH, Garcia D. Perioperative management of anticoagulation: guidelines translated for the clinician. J Thromb Thrombolysis 2009; 28:16-22. [PMID: 19242654 DOI: 10.1007/s11239-009-0313-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Accepted: 02/10/2009] [Indexed: 02/03/2023]
Abstract
The perioperative management of patients taking vitamin K antagonists (VKAs) is an evolving area of medicine and poses significant challenges for health care providers. It has been estimated that this issue affects approximately 250,000 patients annually, and the number of patients requiring chronic anticoagulation continues to increase. The lack of evidence, along with the wide variety of clinical scenarios, requires complex decision making on the part of clinicians. In general, when a patient on chronic anticoagulation requires a planned procedure, the clinician must assess the risk of perioperative thrombotic events and the risk of perioperative bleeding complications and weigh those risks in determining the safest perioperative strategy. We aimed to summarize and provide our opinion about the recommendations from the recent 8th edition of the American College of Chest Physicians (ACCP) guidelines for the perioperative management of antithrombotic therapy.
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Affiliation(s)
- Erik P Kraai
- University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA
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