A 92-year-old woman with a history of hypertension presented several months ago with a deep venous thrombosis that was treated with a non-vitamin K antagonist oral anticoagulant (NOAC) in the form of rivaroxaban. She also had nearly incessant typical AV nodal reentry and recently underwent successful slow pathway ablation. She was admitted to the hospital with recurrent symptomatic sinus node dysfunction and scheduled for implantation of a dual-chamber pacemaker.
The day before her pacemaker implantation, the NOAC was held by the implanting physician. Unfortunately, her other hospital-based providers started her on low-molecular-weight heparin (LMWH) the evening before the procedure. When this was discovered the next morning, her pacemaker implantation was postponed until the next day. Why did this patient receive heparin bridging?
Heparin bridging is a term used to describe the use of short-acting heparin, often in the form of LMWH, when transitioning a patient off and on warfarin in preparation for a procedure or surgery that could be associated with bleeding. Temporary interruption of the heparin allows one to minimize the time the patient is not anticoagulated and lowers the risk of intraoperative bleeding. Over the past few years, however, it has been made clear that perioperative heparin bridging for surgery is associated with significant bleeding, as shown in the ORBIT-AF and BRIDGE trials.1,2 One reason for the high occurrence of post-operative bleeding is likely the use of heparin at doses intended to treat a known clot, such as a deep venous thrombosis, rather than at lower doses intended as prophylaxis. Furthermore, there are several studies3 that have shown that some procedures, including catheter ablation and pacemaker implantation, can safely be performed on uninterrupted warfarin when necessary. Therefore, it is rare that a patient taking warfarin requires heparin bridging. Exceptions include those rare patients who are on warfarin and are at very high risk for thromboembolism, such as patients with a mechanical mitral valve, a recent stroke, or cardioversion in the past month.
The availability of short-acting NOACs has made it much easier to safely manage patients on anticoagulation around the time of surgery. The rapid offset and onset of NOACs obviates the need for bridging anticoagulation. The NOAC should briefly be held preoperatively depending on the type of surgery and renal function, and resumed postoperatively when hemostasis has been achieved. For some reason, however, patients on NOACs are still subjected to perioperative heparin bridging and its associated bleeding risks. There is no basis for heparin bridging in the vast majority of patients on a NOAC. An exception might be when a patient is unable to resume oral medications postoperatively and are at very high risk of stroke.
Perioperative management of patients receiving anticoagulants should follow an evidence-based, common sense approach. An excellent review on the topic is available on UpToDate.4 For patients with atrial fibrillation who are taking a NOAC for stroke prevention, there are few if any reasons to bridge the patient with heparin. When necessary, it is important to use a dose that considers that the goal is to prevent a clot, not treat one.4
Bradley P. Knight, MD, FACC, FHRS
Editor-in-Chief, EP Lab Digest
Disclosures: Dr. Knight reports that he has served as a consultant, speaker, investigator, and/or has received EP fellowship grant support from Abbott, AtriCure, Baylis Medical, Biosense Webster, BIOTRONIK, Boston Scientific, CVRx, Medtronic, Philips, and Sanofi. He has no equity or ownership in any of these companies.
- Steinberg BA, Peterson ED, Kim S, et al. 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). Circulation. 2015;131(5):488-494. Epub 2014 Dec 12. doi: 10.1161/CIRCULATIONAHA.114.011777
- Douketis JD, Spyropoulos AC, Kaatz S, et al, BRIDGE Investigators. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823. Epub 2015 Jun 22.
- Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084-2093. Epub 2013 May 9. doi: 10.1056/NEJMoa1302946
- Douketis JD, Lip GYH. Perioperative management of patients receiving anticoagulants. UpToDate. Accessed April 5, 2021. https://www.uptodate.com/contents/perioperative-management-of-patients-receiving-anticoagulants