Periprocedural Heparin Bridging in Patients Receiving Vitamin K Antagonists: Systematic Review and Meta-Analysis of Bleeding and Thromboembolic Rates
Background—Periprocedural bridging with unfractionated heparin or low molecular weight heparin (LMWH) aims to reduce the risk of thromboembolic (TE) events in patients receiving chronic vitamin K antagonists (VKA). Optimal periprocedural anticoagulation has not been established.
Methods and Results—Search of MEDLINE, EMBASE and Cochrane databases (2001 to 2010) for English-language studies including patients receiving heparin bridging during interruption of VKA for elective procedures. Data were independently collected by 2 investigators (k=0.90). The final review included 34 studies with 1 randomized trial. TE events occurred in 73/7118 bridged patients (pooled incidence 0.9%, 95% confidence interval [CI] 0.0.0%-3.4%) and 32/5160 non-bridged patients (pooled incidence 0.6%, 95%CI 0.0%-1.2%). There was no difference in the risk of TE events in 8 studies comparing bridged versus non-bridged groups (OR 0.80, 95%CI 0.42-1.54). Bridging was associated with an increased risk of overall bleeding in 13 studies (OR 5.40, 95%CI 3.00-9.74) and major bleeding in 5 studies (OR 3.60, 95% CI 1.52-8.50) comparing bridged and non-bridged patients. There was no difference in TE events (OR 0.30, 95%CI 0.04-2.09) but an increased risk of overall bleeding (OR 2.28, 95%CI 1.27-4.08) with full versus prophylactic/intermediate dose LMWH bridging. Low TE risk and/or non-VKA patient groups were used for comparison. Study quality was poor with heterogeneity for some analyses.
Conclusions—VKA-treated patients receiving periprocedural heparin bridging appear to be at increased risk of overall and major bleeding, and similar risk of TE events compared to non-bridged patients. Randomized trials are needed to define the role of periprocedural heparin bridging.
- Received March 14, 2012.
- Accepted August 6, 2012.
- Copyright © 2012, American Heart Association, Inc. All rights reserved. Unauthorized use prohibited