Thromboembolic and bleeding risk of periprocedural bridging anticoagulation: A systematic review and meta-analysis

The risk and benefit of periprocedural heparin bridging is not completely clarified. We aimed to assess the safety and efficacy of bridging anticoagulation prior to invasive procedures or surgery. Heparin bridging was associated with lower risks of thromboembolism and bleeding compared to non-bridging. PubMed, Ovid and Elsevier, and Cochrane Library (2000-2016) were searched for English-language studies. Studies comparing interrupted anticoagulation with or without bridging and continuous oral anticoagulation in patients at moderate-to-high thromboembolic risk before invasive procedures were included. Primary outcomes were thromboembolic events and bleeding events. Mantel-Haenszel method and random-effects models were used to analyze the pooled risk ratio (RR) and 95% confidence interval (CI) for thromboembolic and bleeding risks. Eighteen studies (six randomized controlled trials and 12 cohort studies) were included (N = 23 364). There was no difference in thromboembolic risk between bridged and non-bridged patients (RR: 1.26, 95% CI: 0.61-2.58; RCTs: RR: 0.71, 95% CI: 0.23-2.24; cohorts: RR: 1.45, 95% CI: 0.63-3.37). However, bridging anticoagulation was associated with higher risk of overall bleeding (RR: 2.83, 95% CI: 2.00-4.01; RCTs: RR: 2.24, 95% CI: 0.99-5.09; cohorts: RR: 3.09, 95% CI: 2.07-4.62) and major bleeding (RR: 3.00, 95% CI: 1.78-5.06; RCTs: RR: 2.48, 95% CI: 1.29-4.76; cohorts: RR: 3.22, 95% CI: 1.65-6.32). Bridging anticoagulation was associated with increased bleeding risk compared to non-bridging. Thromboembolism risk was similar between two strategies. Our results do not support routine use of bridging during anticoagulation interruption.