Bridging Therapy: A Challenging Area in the Management of Patients with Atrial Fibrillation

American Journal of Cardiovascular Drugs, Jun 2013

Yutao Guo, Gregory Y. H. Lip, Stavros Apostolakis

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Bridging Therapy: A Challenging Area in the Management of Patients with Atrial Fibrillation

Yutao Guo 0 1 Gregory Y. H. Lip 0 1 Stavros Apostolakis 0 1 0 Y. Guo Department of Geriatric Cardiology, Chinese PLA General Hospital , Beijing, China 1 Y. Guo G. Y. H. Lip S. Apostolakis (&) Haemostasis, Thrombosis and Vascular Biology Unit, University of Birmingham Centre for Cardiovascular Sciences, City Hospital , Dudley Road, Birmingham B18 7QH, UK As part of the comprehensive approach to the management of atrial fibrillation (AF), improving prevention from stroke and thromboembolism (TE) has a high priority [1]. Whilst it is accepted that chronic prophylaxis is valuable, occasional interruption of oral anticoagulation (until recently, warfarin) necessitates bridging therapy with a parenteral anticoagulant, and this is where uncertainties arise [2, 3]. Bridging therapy is usually used for those patients who undergo the initiation or interruption of vitamin K antagonist (VKA) therapy, or have subtherapeutic international normalized ratio (INR) values. The decision regarding bridging therapy should be based on a careful assessment of the risks for TE and bleeding [4]. However, there are limited data about the use of bridging therapy in patients with AF. A study published recently by Smoyer-Tomic et al. [5] found that amongst 3037 inpatients with AF for medical (70%) or surgical admissions (30%), there were 1944 (64%) patients who received bridging therapy. Given the exclusion of pulmonary embolism (PE) and cardiac surgery - in this observational study, the real rate of bridging therapy could possibly be even higher among inpatients with AF. Although definite reasons for bridging are unknown given the limitations of observational data from an administrative claims dataset, most patients would likely have received bridging therapy along with initiation of warfarin as many had no evidence of warfarin use in the 6-month period before hospitalization. Also, bridged patients were more likely to have co-morbid conditions, including atrial flutter, ischemic stroke/transient ischemic attack (TIA)/cerebrovascular disease, and acute myocardial infarction (AMI). In their study, the AF patients who received bridging therapy had a mean CHA2SD2-VASc score of 3.5, consistent with a high risk of TE. It was notable that length of stay (LOS) was longer for bridged than non-bridged patients. This aspect may reflect the patients co-morbidities of such more complex patients. Indeed, for the VKA-nave patient at high risk of thromboembolism undergoing initiation of VKA therapy, a bridge anticoagulant should be considered to minimize the delay in achieving therapeutic anticoagulation. The bridge is administered parentally, thereby providing a near-immediate anticoagulant effect. The bigger challenge for bridging anticoagulant therapy is amongst the chronically anticoagulated patients, who need to temporarily interrupt VKAs because of special situations, e.g. catheter ablation, implantation of a pacemaker or an implantable cardioverter-defibrillator (ICD), percutaneous coronary intervention (PCI), or surgery. The invasive procedure may increase the risk of bleeding, whilst on the other hand interruption of VKAs may confer an increased risk of TE. Besides the risk for stroke, the risk for major adverse cardiac events and stent thrombosis might also increase [68]. Thus, clinicians would need to weigh the risk of TE and bleeding in deciding on bridging. Recently, bleeding risk assessment and management in AF has been comprehensively reviewed by a consensus document from the European Heart Rhythm Association and European Society of Cardiology Working Group on Thrombosis [9]. Similarly, the American College of Chest Physicians issued guidelines to address the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. The consensus was that bridging would be needed for those at high risk of thromboembolism, based on clinical criteria including the CHADS2 (Congestive heart failure, Hypertension [BP [140/90 mmHg], Age C75 years, Diabetes mellitus, prior Stroke or TIA or thromboembolism) score [10]. However, patients with a CHADS2 score 01 are not necessarily low risk, as even amongst a cohort of patients with a CHADS2 score of 0, the rate of thromboembolism can vary between 0.8%/year (CHA2DS2-VASc = 0) and 3.2%/year (CHA2DS2-VASc = 3); indeed, use of the CHA2DS2-VASc score would significantly improve risk stratification of AF patients at low and intermediate risk of stroke based on the commonly used CHADS2 score (score 01) [11]. Many patients undergoing catheter ablation do not need to interrupt oral anticoagulation if the INR is within the therapeutic range [12]. Interruption of anticoagulation preoperatively with heparin bridging in patients with ICD (or other devices) should be considered only if patients are at high risk of TE [12]. With respect to PCI, an uninterrupted strategy can be followed for patients at moderate high or very high risk of TE [68]. When in (...truncated)


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Yutao Guo, Gregory Y. H. Lip, Stavros Apostolakis. Bridging Therapy: A Challenging Area in the Management of Patients with Atrial Fibrillation, American Journal of Cardiovascular Drugs, 2013, pp. 259-261, Volume 13, Issue 4, DOI: 10.1007/s40256-013-0032-5