Perioperative bridging interruption with heparin for the patient receiving long-term anticoagulation

PURPOSE OF REVIEW: To provide a timely and concise review of the most recent clinical data in the field of bridging (anticoagulation) therapy with heparin for the at-risk patient receiving long-term oral anticoagulation who requires temporary interruption for an elective invasive procedure or surgery. RECENT FINDINGS: A recent systematic review found that the quality of studies of bridging therapy published before June 2001 was generally poor. More recent larger prospective cohort studies and registries of patients receiving long-term oral anticoagulation, including patients with mechanical heart valves, who underwent bridging therapy with mostly treatment-dose low-molecular-weight heparin for both major and non-major elective invasive procedures or surgeries have been completed. These studies reveal an overall thromboembolic complication rate of 1.22 (95% CI 0.81-1.77) and an overall major bleed rate of 2.94 (95% CI 2.28-3.74). Standardized low-molecular-weight heparin bridging regimens using postoperative bleeding risk assessments optimized good clinical outcomes, and bridging therapy with low-molecular-weight heparin appears to be at least as safe as unfractionated heparin and produces substantial cost savings through reduction in length of stay in the hospital. SUMMARY: Perioperative bridging therapy with heparin, either unfractionated heparin or low-molecular-weight heparin, appears to be safe and effective for patients, including those with mechanical heart valves, receiving long-term oral anticoagulation who require temporary interruption, especially for non-high-bleeding risk procedures such as minor surgery and invasive procedures. Further studies, including randomized double-blind placebo-controlled trials, are needed to optimize bridging therapy for specific patients and procedures.