Enoxaparin vs Continuous Heparin for Periprocedural Bridging in Patients With Atrial Fibrillation and Advanced Chronic Kidney Disease
Due to this study’s time frame, the clinical pharmacy services at MEDVAMC were not as robust as they are now, which is the reason the decisions on which anticoagulant to use were primarily physician based. The use of TheraDoc to identify patients posed the risk of missing patients who may not have had the appropriate laboratory tests performed (ie, SCr). Patients on UFH had a reduced eGFR compared with that of enoxaparin, which may limit our extrapolation of enoxaparin’s use in end-stage renal disease. The reduced eGFR and higher number of dialysis patients in the UFH arm may have increased the occurrence of more labile INRs and bleeding outcomes. Patients on hemodialysis typically have more comorbidities and an increased risk of infection due to the frequent use of catheters and needles to access the bloodstream. In addition, the potential differences in catheter use and duration between groups were not identified. If these parameters were studied, the data collected may have helped better explain the reasoning for increased incidence of infection in the UFH arm.
Strengths of this study include a complex patient population with similar characteristics, distribution of ethnicities representative of the US population, patients at moderate-to-high thrombotic risk, the analysis of nosocomial infections, and the exclusion of patients with normal renal function or moderate CKD.
Conclusion
To our knowledge, this is the first study to compare periprocedural bridging outcomes and incidence of nosocomial infections in patients with AF and ACKD. This review provides new evidence that in this patient population, enoxaparin is a potential anticoagulant to reduce hospital LOS and hospital-acquired infections. Compared with UFH, bridging with enoxaparin reduced hospital LOS and anticoagulation time-to-discharge by 7 and 5 days, respectively, and decreased the incidence of nosocomial infections by 30%. Using the mean LOS per treating specialty for both arms, bridging 1 patient with AF with enoxaparin vs UFH can potentially lead to an estimated $40,000 (44%) reduction in total cost of hospitalization. Enoxaparin also had no numeric differences in mortality and adverse events (stroke/TIA, MI, VTE) vs that of UFH, but it is important to note that this study was not powered to find a significant difference in these outcomes. Due to the mean eGFR of patients on enoxaparin being 22.6 mL/min/1.73 m2 and only 1 in 5 having stage 5 CKD, at this time, we do not recommend enoxaparin for periprocedural use in stage 5 CKD or in patients on hemodialysis. Larger studies are needed, including randomized trials, in this patient population to further evaluate these outcomes and assess the use of enoxaparin in patients with ACKD.
