Efficacy and Safety of Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation Undergoing Elective Surgical Procedures: A Meta-analysis

Abstract

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.

Risk-adjusted perioperative bridging anticoagulation reduces bleeding complications without increasing thromboembolic events in general and visceral surgery

“…The present study confirms the overall increase of bleeding complications during bridging that has been described in several meta-analyses [ 5 , 21 ]. Although our incidence of bleeding complications declined after implementation of the risk-adjusted regimen, it remained above our previous reported incidence in patients without OAC (10.3% in period 2 vs. 6.1% control group of period 1 [ 8 ]).…”

“…The general necessity of perioperative bridging has been challenged by two randomized controlled trials demonstrating no benefit concerning the incidence of thromboembolism from LMWH bridging in patients on warfarin OAC [ 16 , 18 ]. However, there is yet no consensus whether high risk patients might still profit from LMWH bridging and individual management is still recommended [ 5 , 21 , 23 ]. A single study on bridging in abdominal malignancy surgery reported no increase of bleeding complications or thromboembolism by heparin bridging [ 24 ].…”

Effectiveness of perioperative anticoagulation interruption without heparin bridging on thromboembolic events in patients with atrial fibrillation undergoing elective invasive procedures: a systematic review protocol

“…The latest systematic review on this topic by Siddiqui et al in 2021 considered studies published up to January 2019, and hence does not incorporate the findings of the PERIOP 2 trial published in 2021. 16 As part of our updated systematic review, we will not only incorporate the data from these studies, but also undertake subgroup analysis on patients with high CHA2DS2-VASc scores (ie, 2 or more), as well as those anticoagulated with DOACs, both of which represent gaps in literature that are yet to be answered. Lastly, we will assign a level of certainty to the results of each outcome via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) 17 approach to allow for easy translation into clinical guidelines.…”

“…A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted, and no in-progress systematic reviews on the topic were identified. The latest systematic review on this topic by Siddiqui et al in 2021 considered studies published up to January 2019, and hence does not incorporate the findings of the PERIOP 2 trial published in 2021 16 . As part of our updated systematic review, we will not only incorporate the data from these studies, but also undertake subgroup analysis on patients with high CHA2DS2-VASc scores (ie, 2 or more), as well as those anticoagulated with DOACs, both of which represent gaps in literature that are yet to be answered.…”