There is a need to develop standardized protocols for the interruption of oral anticoagulation for surgery and invasive procedures, according to results of a study published July 4 in the Journal of American College of Cardiology.

Because the management of parenteral anticoagulation is a complex process and requires coordination between health care providers, the ACC Anticoagulation Initiative Work Group developed a survey to help “better understand current practice patterns for patients requiring interruption of anticoagulation therapy.”

In a review of background data, study authors Greg C. Flaker, MD, FACC, et al., note that there is little evidence to show that bridging anticoagulation prevents thromboembolic events (TE). An earlier review and analysis of patients who required interruption of vitamin K antagonist therapy showed “no significant differences in TE between those patients who received parenteral anticoagulation and those who did not.” Significant occurrences of major bleeding were noted in the patients who received parenteral anticoagulation. Similar results were found in the BRIDGE trial in which patients were randomized to dalteparin or placebo. 

The authors also assert that a number of surgical procedures with low bleeding risk can be performed with “brief or no interruption of warfarin,” which reduces the need for parenteral anticoagulation and additional bleeding risk. Further, the incorporation of direct-acting oral anticoagulants (DOACs) into clinical practice has contributed to questions about when parenteral anticoagulation is appropriate.

The survey, completed by 945 physicians involved in the periprocedural management of anticoagulation, found that few respondents had standardized periprocedural protocols at their institutions. The medical professionals charged with making the decision to bridge anticoagulation varied greatly (physicians performing the procedures, primary care physicians, nurses and pharmacists) and the decisions made were found to be inconsistent. The authors explain that the different philosophies and specialties of the physicians involved can result in wide variations in dosage as well as durations of parenteral anticoagulation. The survey also highlights confusion surrounding periprocedural management of anticoagulation in patients treated with a DOAC.  

“It has been shown that when anticoagulation protocols are devised and implemented, low TE and low rates of major bleeding are observed,” note the authors. Flaker, et al., conclude that the survey results represent “an important opportunity for professional societies and guidelines committees to work together to provide meaningful suggestions on the basis of current data.”

“Overall, promotion of anticoagulation education programs and coordination among specialties, pharmacists, nursing and other health care providers are needed to improve anticoagulation patient care,” said Flaker. “The College is in the process of developing a clinical policy document in direct response to this need.”

Listen to the audio commentary by Valentin Fuster, MD, PhD, MACC, editor-in-chief of JACC. 

Keywords: Anticoagulants, Dalteparin, Hemorrhage, Patient Care, Pharmacists, Physicians, Primary Care, Thromboembolism, Vitamin K, Warfarin

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