Heparin Bridging in Anticoagulated Patients: Overused and Possibly Hazardous

Mark S. Link, MD reviewing Steinberg BA et al. Circulation 2014 Dec 12. Shaikh AY and McManus DD. Circulation 2014 Dec 12.

In the prospective ORBIT-AF registry, bridging for AF patients during interrupted chronic anticoagulation was associated with increased risk for bleeding and no stroke-prevention benefit.

Although guidelines exist for use of bridging anticoagulation during short-term interruptions of warfarin in patients with atrial fibrillation, they are based largely on expert opinion. Researchers have now examined the effects of bridging in ORBIT-AF, a prospective, community-based registry of patients with AF. In this registry, 7372 patients were on chronic anticoagulation (AC), of whom 2200 patients underwent 2803 interruptions of AC for medical procedures. ORBIT-AF is sponsored by an anticoagulant manufacturer.

Most interrupted treatments were warfarin (96%); only 4% were dabigatran. During interruptions, bridging anticoagulants were used in 24% (low-molecular-weight heparin in 73% and unfractionated heparin in 15%). As expected, significantly more patients with mechanical valves (9.6% vs. 2.4%) and prior cerebrovascular events (22% vs. 15%) underwent bridging. CHA2DS2-VASc scores did not differ. Bridged patients had more bleeding events (5% vs. 1.3%; adjusted odds ratio, 3.84; P=0.0001). Combined cardiovascular events (myocardial infarction, thromboembolism, major bleeding, hospitalization, and death within 30 days) were also more common in bridged patients (13% vs. 6.3%; adjusted OR, 1.94; P=0.0001). The incidence of thrombotic events was low and similar between those bridged (0.8% during bridging, 0.6% after) and not bridged (0.5% during bridging, 0.3% after).

Citation(s):

Steinberg BA et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation 2014 Dec 12.

Shaikh AY and McManus DD.A bridge too far? Findings of bridging anticoagulation use and outcomes in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation 2014 Dec 12; [e-pub ahead of print].