Response to Letter Regarding Article, “Bridging Evidence-Based Practice and Practice-Based Evidence in Periprocedural Anticoagulation”
We thank Llau et al for their comments on our editorial.1 The challenge in periprocedural management of anticoagulated patients focuses on the need to balance the risk of thromboembolism (in case of anticoagulation interruption) with the risk of bleeding during the procedure (in case of anticoagulation continuation). Some procedures have demonstrated improved outcomes when oral anticoagulation was not discontinued (eg, minor dental, dermatologic procedures, or cataract surgery), and the meta-analysis performed by Siegal et al2 showed an increased risk of bleeding with similar thrombotic risk among patients who underwent periprocedural bridging therapy. Similar results were shown by Feng et al.3
Understandably, novel oral anticoagulants have increased the fear of bleeding during surgery because of the absence of a specific antidote for these drugs. However, theoretical advantages such as rapid onset of action and a short half-life (similar to low-molecular-weight heparins) allow no need of bridging.4
If renal function is impaired, drug clearance for some novel oral anticoagulants (eg, dabigatran) will be slowed. Our algorithm has the advantage of taking into account the bleeding risk of surgery, arguing for control of the hemostasis in the morning before surgery. Although lacking of standardized monitoring, a normal prothrombin time/activate partial thromboplastin time ratio usually exclude an anticoagulation effect resulting from rivaroxaban or dabigatran, respectively.
Patients at high thrombotic risk (such as prostatic valves carriers) or with impaired renal function (creatinine clearance ≤30mL/min) should continue taking vitamin K antagonists, but our algorithm could be nuanced for those patients at moderate thrombotic risk who may benefit from bridging after novel oral anticoagulant discontinuation.
The limited evidence on bridging therapy makes it difficult to openly advocate a single way of practice, and even international guidelines usually provide recommendations with a low grade of evidence. If evidence is limited on the old vitamin K antagonists, even more gaps remain about novel oral anticoagulants, and some controversy in the perioperative period endures. We refer to the expected results of the clinical trials (A Double Blind Randomized Control Trial of Post-Operative Low Molecular Weight Heparin Bridging Therapy Versus Placebo Bridging Therapy for Patients Who Are at High Risk for Arterial Thromboembolism [PERIOP-2], Effectiveness of Bridging Anticoagulation for Surgery [BRIDGE], and Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial [BRUISECONTROL]) mentioned in our editorial that may help to clarify the periprocedural bridging controversy. Until then, the debate will continue.5,6
Pilar Gallego, MD
Stavros Apostolakis, MD, PhD
Gregory Y.H. Lip, MD
University of Birmingham Centre for Cardiovascular Sciences
Dr Lip has served as a consultant for Bayer, Astellas, Merck, Sanofi, BMS/Pfizer, Daiichi-Sankyo, Biotronik, Portola, and Boehringer Ingelheim and has been on the speakers bureau for Bayer, BMS/Pfizer, Boehringer Ingelheim, and Sanofi Aventis. He serves as a DSMB committee member for the BRUISE CONTROL trial. The other authors declare no conflicts of interest.
- © 2013 American Heart Association, Inc.
- Gallego P,
- Apostolakis S,
- Lip GYH
- Siegal D,
- Yudin J,
- Kaatz S,
- Douketis JD,
- Lim W,
- Spyropoulos AC