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Thomas Vanassche, Mandy N. Lauw, Stuart J. Connolly, John W. Eikelboom, Heparin bridging in peri-procedural management of new oral anticoagulant: a bridge too far?, European Heart Journal, Volume 35, Issue 28, 21 July 2014, Pages 1831–1833, https://doi.org/10.1093/eurheartj/ehu034
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This editorial refers to ‘Peri-interventional management of novel oral anticoagulants in daily care: results from the prospective Dresden NOAC registry’‡, by J. Beyer-Westendorf et al., on page 1888.
The new oral anticoagulants (NOACs) are attractive alternatives to vitamin K antagonists (VKAs) for patients requiring long-term anticoagulation. NOACs are at least as effective and safe as warfarin while allowing convenient fixed dosing regimens.1,2 Moreover, due to their rapid onset and offset of action,3 NOACs have the potential to simplify the peri-procedural management of patients requiring interruption of anticoagulant treatment for elective interventions.
Beyer-Westendorf and colleagues now report thrombotic and bleeding outcomes during the first 30 days after an elective procedure from a prospective registry of 2179 patients receiving long-term NOAC therapy for atrial fibrillation (81%), venous thrombo-embolism (17%), or other indications (2%).4 During an 18-month period, 595 patients underwent a total of 863 elective procedures. Most patients were taking rivaroxaban (76%) or dabigatran (23.5%), and only a minority (0.5%) was taking apixaban. Patients who underwent procedures without interruption of NOAC therapy did not experience major bleeding and had a non-major clinically relevant bleed rate of < 5%. Patients who underwent a procedure with interruption of NOAC therapy and who received bridging anticoagulation [40% of patients; most commonly with low molecular weight heparin (LMWH)] had similar rates of thrombotic events compared with those who did not receive bridging (1.6% vs. 0.8%, P = 0.265), but experienced a five-fold increase in major bleeding (2.7% vs. 0.5%, P = 0.01). Rates of non-major clinically relevant and minor bleeding were similar in the two treatment groups irrespective of the use of bridging. Multivariate analysis revealed that the type of procedure (major vs. non-major) was an independent predictor for both thrombotic events [odds ratio (OR) 7.3; 95% confidence interval (CI) 1.9–28.5] and major bleeding (OR 16.8; 95% CI 3.8–78.9). Bridging predicted major bleeding (OR 5.9; 95% CI 1.2–20.4) but did not appear to protect patients against thrombotic events.
