Periprocedural Bridging Anticoagulation

Journal of Hospital Medicine 13(3). 2018 March;:198-201. Published online first January 24, 2018. | 10.12788/jhm.2899

January 17, 2018|Journal of Hospital Medicine

Stacy A. Johnson, MD;Joshua LaBrin, MD, SFHM, FACP

WHAT SHOULD YOU DO INSTEAD?

First, determine whether periprocedural OAC interruption is necessary for patients on chronic OAC due to atrial fibrillation, VTE, or MHVs. Avoid unwarranted OAC interruption by discussing the need for OAC interruptions with the surgeon or proceduralist, especially if the surgery is associated with a low bleeding risk and the patient has a high thromboembolic risk. When a periprocedural OAC interruption is justified, bridging should be avoided in the majority of patients, especially those with low to moderate thromboembolic risk or increased bleeding risk according to current risk-stratification schema.^7,15,19

Periprocedural management of direct oral anticoagulants (DOACs) is different than that of warfarin. The duration of DOAC interruption is determined by the procedural bleeding risk, drug half-life, and a patient’s creatinine clearance. Although the pharmacokinetics of DOACs generally allow for brief interruptions (eg, 24-48 hours), longer interruptions (eg, 96-120 hours) are warranted prior to high bleeding risk procedures, when drug half-life is prolonged (ie, dabigatran), and in patients with renal impairment. Parenteral bridging anticoagulation is not recommended during brief DOAC interruptions, and substituting a DOAC in place of LMWH for bridging is not advised. The 2017 American College of Cardiology Expert Consensus Decision Pathway provides periprocedural OAC interruption guidance for atrial fibrillation, with many principles applicable to other OAC indications.¹⁵We developed an institutional guideline that provides clinicians a structured approach to bridging OAC that steers them away from inappropriate bridging and helps them make decisions when evidence is lacking. Shared decision-making represents another effective method for well-informed patients and clinicians to arrive at a mutually agreed upon bridging decision.

RECOMMENDATIONS

Avoid unnecessary periprocedural interruptions of OAC, especially for procedures with a low bleeding risk.
Avoid the administration of bridging anticoagulation in patients with low to moderate thromboembolic risk during periprocedural OAC interruptions.
In patients with a high thromboembolic risk, an individualized assessment of the patient-specific and procedure-specific bleeding risks versus the thromboembolic risks is necessary when considering bridging anticoagulation administration.

CONCLUSION

Returning to the opening case, the patient requires an anticoagulation interruption and INR correction prior to surgery. Because the CHA₂DS₂VaSc score of 4 does not categorize him as a high thromboembolic risk, bridging anticoagulation should be avoided. In the majority of patients on OAC, bridging anticoagulation does not reduce thromboembolic events and is associated with increased major bleeding. Unnecessary anticoagulation interruptions should be avoided for procedures associated with low bleeding risk. Bridging should not be administered to the majority of patients requiring a periprocedural anticoagulation interruption.

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Disclosure: The authors report no conflicts of interest relevant to this article to disclose.