Periprocedural Anticoagulation Management of Patients With Nonvalvular Atrial Fibrillation

Heparin bridging in warfarin anticoagulation therapy initiation could increase bleeding in non‐valvular atrial fibrillation patients: a multicenter propensity‐matched analysis

“…Several studies have been concerned with heparin-bridging therapy before invasive procedures or surgery, and bridging therapy is generally recommended in AF patients with a high TE risk [8,[16][17][18][19][20][21][22]. Because two large randomized trials are currently under way, it is important to determine whether bridging therapy before invasive procedures or surgery is also needed in patients with low to moderate TE risk [39,40].…”

“…The frequency of heparin bridging in OAC initiation is variously reported to range from 5% to 64% in several retrospective studies [12][13][14][15]. Because 25-50% of patients with AF are asked to interrupt OAC before an invasive procedure or surgery every year, many studies have been published concerning the risk and benefit of bridging anticoagulation, and current international guidelines recommend the use of bridging therapy in AF patients undergoing interruptions of warfarin who are considered to be at high thromboembolic (TE) risk, such as patients with prosthetic heart valves, venous thromboembolism, valvular AF, or AF with higher CHADS 2 scores (estimates risk based on the presence of congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, and prior stroke or transient ischemic attack) [8,[16][17][18][19][20][21][22]. Several studies have demonstrated the reduction of hospital stay [12] and risk of VTE and death [13] in patients who received bridging therapy with heparin.…”

Patients requiring interruption of long‐term oral anticoagulant therapy: the use of fixed sub‐therapeutic doses of low‐molecular‐weight heparin

“…The use of ÔbridgingÕ therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is usually implemented in patients considered to be at intermediate-tohigh risk of TE, such as those with prosthetic heart valves or atrial fibrillation [3][4][5][6][7][8]. Intravenous heparin is attractive as bridging therapy because of its rapid onset of action and short half-life, thus minimizing the exposure time to low anticoagulation [9]; however, such an approach is not easily practicable.…”

“…Intravenous heparin is attractive as bridging therapy because of its rapid onset of action and short half-life, thus minimizing the exposure time to low anticoagulation [9]; however, such an approach is not easily practicable. The use of LMWH is feasible but its optimal management in this setting is uncertain [3][4][5][6][7][8][9][10]. Another potential strategy is to continue oral anticoagulation therapy with a temporary adjustment of warfarin intensity to a preoperative international normalized ratio (INR) of 1.5-2.0, but such an approach has shown a high rate of bleeding [11].…”

Anticoagulation, Novel Agents, and Procedures

“…3 However, observational studies indicate that many (if not most) AF patients who simply interrupt warfarin for Ͻ7 days (without bridging) have a very low risk of stroke. 4,5 Even if one presumes that periprocedural anticoagulant (bridge) therapy can reduce this already low risk of stroke after warfarin interruption, the net clinical benefit is unclear because the extent to which bridging therapy increases major bleeding is not known. One prospective cohort study of 224 consecutive patients who received LMWH as periprocedural anticoagulation reported a major bleeding rate of 6.7% (95% confidence interval, 4.1-10.8), 6 raising questions about whether in some scenarios bridging may do more harm than good.…”