“Dr. Reznick I need to have a tooth extracted my dentist wants me to stop my Coumadin. What do you think?”
Not a day goes by without a similar question being asked in the practice. It could be a question about stopping warfarin prior to numerous surgical interventions that need your blood to clot to provide hemostasis during and after the procedure. Many of my patients take anticoagulants because their basic heart rhythm is atrial fibrillation and they are trying to avoid the embolic strokes that can occur 2-3 times more frequently in patients with this heart rhythm. Other patients are recovering from phlebitis or a deep vein thrombosis or an embolic episode like a pulmonary embolism and are in the first six months of treatment with an anticoagulant. Many of these patients are placed on heparin infusions or injections daily to continue the anticoagulation prior to the procedure. The advantage of the heparin is that once it is stopped, you are no longer anticoagulated within minutes to hours and you can undergo surgery with a normal risk or so we thought. After the surgery , your oral anticoagulant is usually restarted after the surgical wound has stopped bleeding and in some cases you are placed back on heparin bridging or interim therapy until the oral anticoagulant is effective sometimes requiring two or three days of the interim therapy. . This practice of using a short acting anticoagulant is known as “bridging.”
In the May 26 addition of JAMA Internal Medicine online, MedPage is reporting that the risk of bleeding from bridging was much higher (2.7%) compared to a non-bridged group (0.2%) in a study of 1812 procedures in which 555 used bridging. Clinically relevant bleeding did not differ in those receiving a therapeutic dose of bridging anticoagulant as opposed to a prophylactic dosage. Over half the bleeding events were complications of the procedure, with one third related directly to the bridging agent injection. The prophylactic dose of a bridging agent is usually lower than the therapeutic dosage.
When the study looked at the patients who did not receive bridging they found that the number of recurrent venous thromboembolism cases was no different in the bridge and non-bridge groups. In this study group the risk of bleeding associated with bridging appeared to outweigh the benefits.
In commentary on the study various experts talked about the lack of necessity of using a bridging agent in a low risk patient. They defined a high risk patient as one with a chemical hypercoaguable condition, patients with recurrent thromboembolic events, a thrombotic event in the previous 4-6 weeks or a recent catastrophic thrombosis (massive pulmonary embolism). They all agreed that they probably would not bridge anyone but high risk patients. They feel most other victims of thromboembolic disease are low risk and may not need bridging.
The study had several short comings including not identifying the “bridging medications.” Did they use unfractionated heparin or enoxaparin or fodaparinux? Researchers additionally need to look at individual procedures and bridging to see if one particular type of surgery or another is more or less prone to post procedure bleeding when bridging is used. In our practice we will continue to consult with the patient’s surgeon or dentist, cardiologist, pulmonologist or hematologist to individualize the decision. With the data suggesting an increased risk of bleeding with bridging in certain groups of patients our decision making has certainly been influenced by new data.
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