Safety and Cost-Effectiveness of Bridge Therapies for Invasive Dental Procedures in Patients with Mechanical Heart Valves

Abstract

PurposeBridge anticoagulation therapy is mostly utilized in patients with mechanical heart valves (MHV) receiving warfarin therapy during invasive dental procedures because of the risk of excessive bleeding related to highly vascular supporting dental structures. Bridge therapy using low molecular weight heparin may be an attractive option for invasive dental procedures; however, its safety and cost-effectiveness compared with unfractionated heparin (UFH) is uncertain.Materials and MethodsThis study investigated the safety and cost-effectiveness of enoxaparin in comparison to UFH for bridge therapy in 165 consecutive patients (57±11 years, 35% men) with MHV who underwent invasive dental procedures.ResultsThis study included 75 patients treated with UFH-based bridge therapy (45%) and 90 patients treated with enoxaparin-based bridge therapy (55%). The bleeding risk of dental procedures and the incidence of clinical adverse outcomes were not significantly different between the UFH group and the enoxaparin group. However, total medical costs were significantly lower in the enoxaparin group than in the UFH group (p<0.001). After multivariate adjustment, old age (≥65 years) was significantly associated with an increased risk of total bleeding independent of bridging methods (odds ratio, 2.51; 95% confidence interval, 1.15-5.48; p=0.022). Enoxaparin-based bridge therapy (β=-0.694, p<0.001) and major bleeding (β=0.296, p=0.045) were significantly associated with the medical costs within 30 days after dental procedures.ConclusionConsidering the benefit of enoxaparin in cost-effectiveness, enoxaparin may be more efficient than UFH for bridge therapy in patients with MHV who required invasive dental procedures.

Bridge Therapy Outcomes in Patients With Mechanical Heart Valves

“…15 A prospective cohort of patients with MHV who had a dental procedure in the setting of bridge therapy identified a 30-day bleeding rate of 5.4% with 1 TE complication (0.6%). 16 Unfortunately, outcomes in patients not receiving bridge therapy were not assessed. 16 Daniels and colleagues performed a cohort study of patients with MHV who had an invasive procedure with or without bridge therapy.…”

“…16 Unfortunately, outcomes in patients not receiving bridge therapy were not assessed. 16 Daniels and colleagues performed a cohort study of patients with MHV who had an invasive procedure with or without bridge therapy. 17 Similar to our study, the rates of TE were very low and equivalent in the bridged and unbridged groups, while major bleeding was numerically greater in the setting of bridge therapy.…”

Effects of heparinoid bridging in patients with mechanical heart valves

“…The average age of the participants ranged from 57 to 67 years, and the participants were predominantly men. The studies included more aortic MHVs, except for the study by Won et al (2014). The risk factors for TEs reported by each study were heart failure, diabetes mellitus, history of thrombosis, atrial fibrillation (AF), and previous stroke or TIA.…”

“…The study by Hart et al (2017) only reported specific procedures in relation to complications, but did not provide an all-inclusive list of procedures. Won et al (2014) only studied participants who underwent dental procedures with a moderate or high risk of bleeding. The other three studies listed and categorized similar high risk of bleeding invasive procedures or surgeries by specialty such as orthopedic, cardiothoracic, interventional radiology, general surgery, ophthalmologic, gynecological, vascular, and procedures of the ear, nose, and throat.…”

“…The studies by Daniels et al (2009) and Attaya et al (2013) excluded patients from being bridged with LMWH if their creatinine clearance was less than 30 ml/min. The study by Won et al (2014) excluded any patient who had their MHV replacement less than 3 months from the beginning of the study. Patients with no clear evidence of a bridging therapy used were excluded by Hart et al (2017) in their study.…”