Perioperative Management in Patients Using Vitamin K Antagonists: Observational Cohort Study

Abstract

Background The benefit of periprocedural bridging with low-molecular-weight heparin (LMWH) in patients with atrial fibrillation has been contested by the publication of the BRIDGE trial.

Objective This article determines whether publication of the BRIDGE trial has led to less bridging procedures and better patient outcomes (i.e., a composite of thromboembolism, major bleeding, and death) in patients undergoing invasive procedures at the Leiden Anticoagulation Clinic, the Netherlands.

Methods We identified all procedures that required vitamin K antagonist interruption. Procedures were divided in a period before (2014–2016; 22 months) and after the publication of the BRIDGE trial (2016–2017; 22 months). Cumulative incidences 30 days postprocedure and relative risks of thromboembolic events, major bleeding, and mortality were calculated.

Results A total of 4,892 and 4,237 eligible procedures were performed in 2014 to 2016 and 2016 to 2017, respectively. The cumulative incidence of thromboembolism was 0.5% in 2014 to 2016 compared with 0.3% in 2016 to 2017; adjusted odds ratio (OR) 0.60 (95% confidence interval [CI] 0.30–1.21). The cumulative incidence of major bleeding was 1.0% in the 2014 to 2016 period as compared with 1.3% in the 2016 to 2017 period; adjusted OR was 1.27 (95% CI 0.85–1.90). The adjusted OR of the composite endpoint was 1.05 (95% CI 0.74–1.48). The frequency of bridging with LMWH (14.8% in 2014–2016 vs. 16.6% in 2016–2017) as well as mean CHA₂DS₂-VASc scores of patients receiving bridging did not change after publication of the BRIDGE trial.

Conclusion We showed that despite publication of the BRIDGE trial, the frequency of bridging with LMWH and patient outcomes regarding bleeding complications did not change.

Keywords

anticoagulants - guideline adherence - hemorrhage - surgery - thromboembolism

Note

This study was performed by J.L.I. Burggraaf within the Master's degree program in Medicine of Leiden University. This study was not funded.

Authors' Contributions

J.L.I. Burggraaf analyzed the data and wrote the manuscript. N. van Rein performed data analyses and revised the manuscript. W.M. Lijfering designed the analysis and revised the manuscript. F.J.M. van der Meer provided data from the Leiden Anticoagulation Clinic and revised the manuscript. All authors gave final approval of the version to be published.

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