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) | Journal Scan
What are the usage patterns and outcomes associated with periprocedural anticoagulation bridging?
Using the ORBIT-AF registry of atrial fibrillation patients, all temporary interruptions of an oral anticoagulant (OAC) for procedures were identified, including the use of any bridging anticoagulation. Thirty-day outcomes assessed included myocardial infarction (MI), stroke or systemic embolism (SSE), major bleeding, cause-specific hospitalization, and death.
Of the 7,372 atrial fibrillation patients treated with an OAC, 2,903 interruptions in anticoagulation occurred in 2,200 patients (30%), with a median follow-up of 2 years. Bridging anticoagulation was used in 665 patients (24%), primarily low-molecular weight heparin (n = 487, 73%) and unfractionated heparin (n = 97, 15%). Bridged patients were more likely to have had a prior cerebrovascular event (22% vs. 15%, p < 0.001) and a mechanical valve replacement (9.6% vs 2.4%, p < 0.001). The mean CHA2DS2-VASc score was higher in the bridged group (4.25 vs. 4.03; p = 0.01). Bleeding events were more common in bridged patients than nonbridged patients (5.0% vs. 1.3%, adjusted odds ratio, 3.84; p < 0.001). The combined incidence of MI, SSE, major bleeding, hospitalizations, or death within 30 days were more common in bridged versus nonbridged patients (13% vs. 6.3%; adjusted OR, 1.94; p < 0.001).
The authors concluded that bridging anticoagulation is used in approximately one-quarter of all OAC interruptions, and is associated with higher risks for bleeding and adverse events. The authors concluded that their data do not support the use of routine bridging for all patients receiving OAC.
This study highlights the real-world practice of bridging patients on OAC for procedures. While they demonstrated increased use of bridging in patients with a prior stroke or mechanical valve replacement, there was only a marginally higher mean CHA2DS2-VASc score in the bridged group. Importantly, patients who were bridged experienced higher rates of adverse events, including major bleeding, without a difference in the rate of stroke or systemic embolism. It is interesting to note that the rates of periprocedure thrombotic events (0.6%) were far lower than the rates of periprocedure major bleeding (2.2%). This study adds to the mounting evidence that routine use of bridging may be harmful. We eagerly await the results of the randomized BRIDGE trial (NCT00786474) to finally answer if routine use of bridging anticoagulation is safe and necessary for temporary interruptions of anticoagulation.
Keywords: Anticoagulants, Atrial Fibrillation, Embolism, Hemorrhage, Heparin, Heparin, Low-Molecular-Weight, Hospitalization, Myocardial Infarction, Stroke, Registries
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