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Medline ® Abstract for Reference 59

of 'Perioperative management of patients receiving anticoagulants'

Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF).
Steinberg BA, Peterson ED, Kim S, Thomas L, Gersh BJ, Fonarow GC, Kowey PR, Mahaffey KW, Sherwood MW, Chang P, Piccini JP, Ansell J, Outcomes Registry for Better Informed Treatment of Atrial Fibrillation Investigators and Patients
Circulation. 2015;131(5):488. Epub 2014 Dec 12.
BACKGROUND: Temporary interruption of oral anticoagulation for procedures is often required, and some propose using bridging anticoagulation. However, the use and outcomes of bridging during oral anticoagulation interruptions in clinical practice are unknown.
METHODS AND RESULTS: The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry is a prospective, observational registry study of US outpatients with atrial fibrillation. We recorded incident temporary interruptions of oral anticoagulation for a procedure, including the use and type of bridging therapy. Outcomes included multivariable-adjusted rates of myocardial infarction, stroke or systemic embolism, major bleeding, cause-specific hospitalization, and death within 30 days. Of 7372 patients treated with oral anticoagulation, 2803 overall interruption events occurred in 2200 patients (30%) at a median follow-up of 2 years. Bridging anticoagulants were used in 24% (n=665), predominantly low-molecular-weight heparin (73%, n=487) and unfractionated heparin (15%, n=97). Bridged patients were more likely to have had prior cerebrovascular events (22% versus 15%; P=0.0003) and mechanical valve replacements (9.6% versus 2.4%; P<0.0001); however, there was no difference in CHA2DS2-VASc scores (scores≥2 in 94% versus 95%; P=0.5). Bleeding events were more common in bridged than nonbridged patients (5.0% versus 1.3%; adjusted odds ratio, 3.84; P<0.0001). The incidence of myocardial infarction, stroke or systemic embolism, major bleeding, hospitalization, or death within 30 days was also significantly higher in patients receiving bridging (13% versus 6.3%; adjusted odds ratio, 1.94; P=0.0001).
CONCLUSIONS: Bridging anticoagulation is used in one quarter of anticoagulation interruptions and is associated with higher risk for bleeding and adverse events. These data do not support the use of routine bridging, and additional data are needed to identify best practices concerning anticoagulation interruptions.
CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01165710.
From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.). benjamin.steinberg@duke.edu.