Title:Safety and Efficacy of Bridging with Low Molecular Weight Heparins: A Systematic Review and Partial Meta-Analysis
Volume: 19
Issue: 22
Author(s): Pieter Eijgenraam, Hugo ten Cate and Arina ten Cate-Hoek
Affiliation:
Keywords:
Thrombosis, bleeding, systematic review, surgery, anticoagulants, vitamin K antagonists, low molecular weight heparins.
Abstract: Background: Surgical interventions in patients on long term vitamin K antagonist (VKA) treatment create a dilemma; periprocedural
interruption of anticoagulation raises the risk of thrombosis, while continuation raises the risk of bleeding. The anticoagulation-
free interval is minimized by “bridging” with parenteral anticoagulants. The efficacy and safety of bridging with low molecular
weight heparins (LMWH) has however not been unequivocally established.
Methods: We performed an EMBASE and MEDLINE search for studies that compared bridging anticoagulation with continuation or
cessation of VKA without bridging; with thromboembolism (TE) and bleeding as outcomes. We identified 878 articles and finally selected
17. Results of individual studies were pooled.
Results: None of the included studies reported significant differences in incidence of TEs between the bridging group and the comparator
group; 4 out of 13 studies reported zero TEs. Heparin was identified as a risk factor for bleeding in multivariable adjusted analyses in 3
studies on pacemaker/implantable cardioverter defibrillator (PM/ICD) surgery. In 5 studies (different types of surgery) with unadjusted
analyses, bridging was compared to warfarin cessation: 3 studies reported null results for bleeding; 2 studies identified bridging as a risk
factor. We pooled a subset of 6 studies regarding postoperative bleeding after PM/ICD surgery and found a relative risk (RR) of 3.03
(95% confidence interval (CI), 1.86-4.95) for bridging compared to continuation of VKA.
Conclusions: While the antithrombotic efficacy of bridging with LMWH has not been demonstrated, increased bleeding risk is observed
in different types of surgery. PM/ICD surgery can be safely performed on continued VKA.
