Abstract
Emerging evidence suggests the use of peri-procedural bridging during interruptions in warfarin therapy increases bleed risk without reducing thromboembolic events. We implemented a peri-procedural anticoagulant management risk assessment tool in a single, outpatient anticoagulation clinic within an academic teaching institution. In this retrospective, pre-post observational study, we evaluated adults who required an interruption in warfarin therapy for an invasive procedure. The primary outcome was the proportion of patients who received bridging prior to and following implementation of the tool. Secondary outcomes included major bleeding, clinically relevant non-major bleeding, thromboembolic events, and other surgical complications within 30 days of the index procedure. In total, 149 patients were included. Bridging was recommended in 60% of the pre-intervention group and in 39.3% of the post-intervention group (p = 0.012). There were no significant differences in the secondary outcomes between the groups. However, patients who received bridging had numerically more bleeding events than patients who did not (12.3 vs. 3.9%, p = 0.102), and patients who received therapeutic dose bridging had more bleeding events than those who received modified dose bridging (10.9 vs. 1.4%, p = 0.466). Following implementation of the tool, there was a statistically significant decrease in the number of patients who received bridging without an increase in thromboembolic events. There were numerically higher rates of bleeding in those who received bridging. Additional research is needed to evaluate efficacy and safety of prophylactic versus treatment dose bridging and how implementation of peri-procedural antithrombotic tools reflecting the emerging evidence will affect patient outcomes, satisfaction and healthcare costs.
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References
Douketis JD, Spyropoulos AC, Spencer FA et al (2012) Perioperative management of antithrombotic therapy. Chest 141(2 suppl):e326S–e350S. https://doi.org/10.1378/chest.11-2298
Clark NP, Witt DM, Davies LE et al (2015) Bleeding, recurrent venous thromboembolism, and mortality risks during warfarin interruption for invasive procedures. J Am Med Assoc Intern Med 175(7):1163–1168. https://doi.org/10.1001/jamainternmed.2015.1843
Rose AJ, Allen AL, Minichello T (2016) A call to reduce the use of bridging anticoagulation. Circulation 9(1):64–67. https://doi.org/10.1161/CIRCOUTCOMES.115.002430
Douketis JD, Spyropoulos AC, Kaatz S et al (2015) Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med 373(9):823–833. https://doi.org/10.1056/NEJMoa1501035
Spyropoulos AC, Al-Badri A, Sherwood MW et al (2016) Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery. J Thromb Haemost 14:875–885. https://doi.org/10.1111/jth.13305
Harris PA, Taylor R, Thielke R et al (2009) Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42(2):377–381. https://doi.org/10.1016/j.jbi.2008.08.010
Schulman S, Angerås U, Bergqvist D, Eriksson B, Lassen MR, Fisher W, on behalf of the subcommittee on control of anticoagulation of the scientific and standardization committee of the international society on thrombosis and haemostasis (2010) Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients. J Thromb Haemost 8(1):202–204. https://doi.org/10.1111/j.1538-7836.2009.03678.x
Kaatz S, Ahmad D, Spyropoulos AC, Schulman S, for the Subcommittee on Control of Anticoagulation (2015) Definition of clinically relevant non-major bleeding in studies of anticoagulants in atrial fibrillation and venous thromboembolic disease in non-surgical patients: communication from the SSC of the ISTH. J Thromb Haemost 13:2119–2126. https://doi.org/10.1111/jth.13140
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Marquez, J., Togami, J.C., Dant, C.R. et al. Peri-procedural antithrombotic management: time to burn the bridge?. J Thromb Thrombolysis 45, 337–344 (2018). https://doi.org/10.1007/s11239-018-1616-3
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DOI: https://doi.org/10.1007/s11239-018-1616-3