Periprocedural Bridging Management of Anticoagulation

More than 2.5 million Americans are chronically anticoagulated for indications including venous thromboembolism (VTE), mechanical heart valve(s), or atrial fibrillation (AF).1 Each year, ≈10% of these patients require temporary interruption of anticoagulation for an invasive procedure. Defining the most appropriate management strategy for these patients requires an assessment of the periprocedural risk of thromboembolism and major hemorrhage. Bridging therapy is a recent term used to describe the application of a parenteral, short-acting anticoagulant during the interruption of warfarin. In this Clinician Update, we outline a systematic approach to defining the appropriate periprocedural strategy for anticoagulation management.A 78-year-old man is scheduled for elective colonoscopy with polypectomy next week. He is receiving chronic warfarin for stroke prevention in paroxysmal AF. He has no prior history of stroke, diabetes mellitus, or heart failure. He is treated with metoprolol both for hypertension and rate control. His international normalized ratio (INR) is well controlled on a stable warfarin dose, and he has no history of major bleeding.A 66-year-old woman was diagnosed with a first life-time right femoral-popliteal DVT 6 weeks ago. She is currently fully anticoagulated with warfarin. As part of her general medical examination, she is found to have ovarian cancer limited to her right ovary without obvious metastases. She is scheduled for total abdominal hysterectomy with bilateral oophorectomy in 5 days. Her INR is 2.2, and her creatinine clearance is 60 mL/min.There is no universal strategy for periprocedural anticoagulation for patients on chronic warfarin therapy. However, a stepwise approach can be useful (Figure 1). In urgent/emergent settings, there is neither time nor opportunity for “bridging” therapy. Warfarin can be reversed with fresh-frozen plasma and parenteral vitamin K.Figure 1. Bridging algorithm for warfarin. Patients with low thrombosis risk include those with aortic bileaflet MHV in sinus rhythm and no previous thromboembolism; …