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Anticoagulation bridging around device surgery: compliance with guidelines
Mark J Perrin1, Brian Z Vezi, Andrew C Ha
1Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada.
Insights
Bridging anticoagulation is underused postoperatively for high-risk patients and overused for low-risk patients undergoing cardiac device surgery, leading to complications. Adherence to guidelines is crucial for safe and effective patient care.
Area of Science:
- Cardiology
- Thrombosis Management
- Medical Device Surgery
Background:
- Current guidelines recommend bridging anticoagulation for moderate/high thromboembolic risk patients during cardiac rhythm device surgery.
- Low-risk patients are advised to stop oral anticoagulation without bridging.
- Real-world adherence to these guidelines and associated clinical outcomes require examination.
Purpose of the Study:
- To assess adherence to current guidelines for bridging anticoagulation in patients undergoing cardiac rhythm device surgery.
- To evaluate the clinical sequelae, including bleeding and thromboembolism, of nonadherence to these guidelines.
Main Methods:
- A retrospective review of 129 patients on chronic anticoagulation undergoing device surgery was conducted.
- Patients were risk-stratified into 'moderate/high' or 'low' risk groups for thromboembolism per American College of Chest Physicians guidelines.
- Perioperative anticoagulation management was compared to guidelines, and rates of bleeding and thromboembolism were assessed.
Main Results:
- Of 129 patients, 62 were moderate/high risk and 67 were low risk.
- Bridging anticoagulation was underutilized postoperatively in 40% of moderate/high-risk patients.
- Bridging was overused in 33% of low-risk patients, associated with bleeding complications (4/10 cases). No perioperative thromboembolisms occurred.
Conclusions:
- Significant underutilization of postoperative bridging anticoagulation was observed in moderate/high-risk patients.
- Overuse of bridging in low-risk patients was linked to bleeding complications.
- Physicians must adhere to expert guidelines for bridging anticoagulation in cardiac rhythm device surgery.
Background:
Current guidelines recommend bridging anticoagulation in patients undergoing cardiac rhythm device surgery with a "moderate to high risk" of thromboembolism. Patients at "low risk" are advised to stop oral anticoagulation without bridging to the procedure. This study examines real world adherence to accepted guidelines and the clinical sequelae of nonadherence.
Methods:
We performed a review of all patients undergoing device surgery receiving chronic anticoagulation over a prespecified time period of 14 months. Patients were classified per American College of Chest Physician guidelines as "moderate/high risk" or "low risk" of thromboembolism. We then compared perioperative management of anticoagulation to guideline recommendations and assessed the rate of perioperative bleeding and thromboembolism.
Results:
One hundred and twenty-nine patients were included in this study. Sixty-two (48%) were classified as "moderate/high risk" and 67 (52%) "low risk." In the "moderate/high risk" group 47/62 (76%) received perioperative anticoagulation but only 25/62 (40%) were bridged both pre- and postprocedure or maintained on uninterrupted warfarin. In the "low risk" group, 22/67 (33%) received bridging therapy. Device pocket hematoma or perioperative bleeding occurred in 10/129 (8%) with 4/10 receiving inappropriate bridging for a calculated low risk of thromboembolism. There were no perioperative thromboembolisms.
Conclusions:
Our study identified significant underutilization of bridging, particularly in the postoperative period, in patients at "moderate/high risk" of thromboembolism. Conversely, bridging was overused in "low risk" patients and associated with bleeding complications. Physicians should be urged to follow current expert guidelines in regard to bridging anticoagulation for cardiac rhythm device surgery. (PACE 2012;35:1480-1486).
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