6 – Should bridging by an injectable anticoagulation be considered in patients who are on chronic anticoagulation prior to undergoing elective orthopaedic procedures?
Arjun Saxena, P. Maxwell Courtney.
Response/Recommendation: Patients on chronic oral anticoagulation for venous thromboembolism (VTE) prevention or non-valvular atrial fibrillation should not be bridged with low-molecular-weight heparin (LMWH) or intravenous unfractionated heparin prior to elective orthopaedic procedures. Several high-quality studies demonstrate an increased risk of perioperative bleeding complications with no difference in thromboembolic events in patients undergoing bridging anticoagulation therapy. For patients on oral anticoagulation for prosthetic heart valve, bridging should be considered weighing the patient’s risk of thromboembolic events versus the risk of bleeding.
Strength of Recommendation: Strong.
Rationale: Many patients are on chronic anticoagulation for prevention of VTE or stroke from atrial fibrillation and approximately 250,000 require interruption of treatment for surgical procedures1. Bridging with intravenous unfractionated heparin or low-molecular-weight heparin (LMWH) prior to surgery has been described to minimize VTE, but it is not without risks.
The American College of Cardiology issued consensus guidelines in 2017 for periprocedural anticoagulation. Patients on direct oral anticoagulation (apixiban, betrixaban, dabigatran, edoxaban, rivaroxaban) rarely need bridging preoperatively due to the short half-life of these medications1. They suggest patients on vitamin K agonists (such as warfarin) may benefit from bridging therapy as these medications have longer half-lives and take longer to become therapeutic after surgery but recognize the risk of bleeding1. One study on patients being treated with warfarin to prevent VTE demonstrated an increased risk of bleeding in patients undergoing bridging therapy versus those who did not2.
In a randomized double-blinded placebo control trial, 1,884 patients on warfarin therapy for treatment of atrial fibrillation received bridging therapy with LMWH or a placebo. The placebo group demonstrated non-inferiority for arterial thromboembolism (0.4% placebo versus 0.3%) and a statistically significant decreased incidence of bleeding events (1.3% placebo versus 3.2%)3. The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) (7,372 patients) also demonstrated higher risk for bleeding and adverse events in patients using bridging anticoagulants as did several other institutional-level studies4–6. Another study utilizing the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) database demonstrates increased bleeding events in patients on chronic dabigatran (6.5% in bridged patients versus 1.8%) and warfarin treatment (6.8% in bridged patients versus 1.6%) without differences in VTE rates7.
Data is limited regarding perioperative anticoagulation management of patients with a prosthetic heart valve. Since these patients are at a much higher risk for an embolic event, bridging should be considered weighing the patient’s risk of thromboembolic events versus the risk of bleeding after consultation with the patient’s cardiologist. While there is no validated perioperative assessment tool, congestive heart failure, hypertension, age > 75 years, diabetes, history of stroke or vascular disease, and female gender are all risk factors for stroke risk in these patients1,8.
A recent randomized controlled trial performed over 9 years in 1471 patients demonstrated no significant benefit for postoperative dalteparin bridging to prevent VTE. The rate of major thromboembolism was 1.2% (eight events in 650 patients) for placebo and 1.0% (eight events in 820 patients) for dalteparen. The study comprised of 1166 patients with atrial fibrillation alone and 305 patients with mechanical heart valves and atrial fibrillation9.
References:
1. Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol. 2017;69(7):871-898. doi:10.1016/j.jacc.2016.11.024
2. Clark NP, Witt DM, Davies LE, et al. Bleeding, Recurrent Venous Thromboembolism, and Mortality Risks During Warfarin Interruption for Invasive Procedures. JAMA Intern Med. 2015;175(7):1163-1168. doi:10.1001/jamainternmed.2015.1843
3. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015;373(9):823-833. doi:10.1056/NEJMoa1501035
4. Krishnamoorthy A, Ortel T. A Bridge to Nowhere? Benefits and Risks for Periprocedural Anticoagulation in Atrial Fibrillation. Curr Cardiol Rep. 2016;18(10):101. doi:10.1007/s11886-016-0779-9
5. Lock JF, Ungeheuer L, Borst P, et al. Markedly increased risk of postoperative bleeding complications during perioperative bridging anticoagulation in general and visceral surgery. Perioper Med (Lond). 2020;9(1):39. doi:10.1186/s13741-020-00170-4
6. Steinberg BA, Peterson ED, Kim S, 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. 2015;131(5):488-494. doi:10.1161/CIRCULATIONAHA.114.011777
7. Douketis JD, Healey JS, Brueckmann M, et al. Perioperative bridging anticoagulation during dabigatran or warfarin interruption among patients who had an elective surgery or procedure. Substudy of the RE-LY trial. Thromb Haemost. 2015;113(3):625-632. doi:10.1160/TH14-04-0305
8. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e72-e227. doi:10.1161/CIR.0000000000000923