Periprocedural Bridging Anticoagulation

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Oral anticoagulation (OAC) is commonly prescribed to patients with atrial fibrillation, venous thromboembolism (VTE), and mechanical heart valves (MHVs) for primary and secondary thromboembolism prevention. When patients require surgery or an invasive procedure, “bridging” anticoagulants (eg, enoxaparin) are commonly administered during the period of OAC interruption to reduce thromboembolic risk. This practice stems from small observational studies and expert opinion, which influenced several clinical guidelines despite the lack of high-quality evidence. Although prospective randomized trials of periprocedural bridging in patients with VTE and MHVs are lacking, available evidence is consistent with findings from the BRIDGE trial, which guides the following general recommendations: (1) avoid unnecessary periprocedural interruptions of OAC, especially for low bleeding risk procedures; (2) avoid the administration of periprocedural bridging anticoagulation in patients with low to moderate thromboembolic risk; (3) in patients with high thromboembolic risk, individually assess the patient-specific and procedure-specific bleeding risks versus thromboembolic risks.

A 75-year-old man with a history of hypertension, diabetes mellitus, and atrial fibrillation is admitted for surgical repair of a comminuted intertrochanteric left hip fracture. He suffered a mechanical ground-level fall without loss of consciousness. At baseline, he denies any chest pain, dyspnea on exertion, or recent change in his exercise tolerance. A physical examination is notable for stable vital signs, irregular cardiac rhythm, and a shortened and externally rotated left lower extremity with exquisite tenderness to palpation and range of motion. The patient is taking warfarin for stroke prophylaxis based on a CHA₂DS₂VaSc score of 4 points. The international normalized ratio (INR) is 1.9 upon admission, and surgery is planned within 48 hours, once the patient is “medically cleared.” Will this patient benefit from periprocedural bridging anticoagulation?

OAC is commonly prescribed to patients with atrial fibrillation, venous thromboembolism (VTE), and mechanical heart valves (MHVs) for the primary or secondary prevention of thromboembolic events, with more than 35 million prescriptions written annually in the United States alone.¹ Many of these patients will require a temporary interruption of their OAC for surgery or an invasive procedure.² As a result, patients may be treated with short-acting, or “bridging,” anticoagulants, such as low-molecular-weight heparin (LMWH), to minimize the duration of anticoagulation interruption and theoretically reduce their thromboembolic risk. The rationale for bridging stemmed from small observational studies and expert opinion that perceived the estimated thromboembolic risk to be higher than the estimated bleeding risk.^3-5 One such example estimated that the VTE risk increased 100-fold postoperatively, whereas heparin administration only doubled the bleeding risk.³ Furthermore, clinical practice guidelines published from the American Heart Association, American College of Cardiology, European Heart Rhythm Society, and American College of Chest Physicians recommend when and how to initiate bridging anticoagulation. Clinicians have widely adopted these recommendations despite an acknowledged paucity of high-quality supporting evidence.^6,7

Periprocedural Anticoagulation Interruption is Often Not Indicated

Patients undergoing a surgical or invasive procedure may require an interruption of OAC to minimize the periprocedural bleeding risk. The decision to interrupt OAC should generally be based on the procedure-specific bleeding risk. Procedures with low bleeding risk such as cataract surgery, dermatologic biopsy (including Mohs), arthrocentesis, diagnostic gastrointestinal endoscopy, and cardiac pacemaker implantation can be performed safely without OAC interruption.^5,7 Despite evidence supporting the safety of periprocedural OAC continuation, unnecessary OAC interruptions remain commonplace and are associated with increased adverse outcomes.⁸ The BRUISE CONTROL trial compared uninterrupted OAC to interrupted OAC with periprocedural bridging for cardiac pacemaker or defibrillator implantation in a moderate to high thromboembolic risk population. The uninterrupted OAC group experienced significantly fewer pocket hematomas, hematoma evacuations, and prolonged hospitalizations (relative risk [RR] 0.19-0.24; P < .05) without significantly increased thromboembolic events, highlighting the potential benefits of this approach.⁹