Clinical question: Is post-procedural bridging therapy necessary for secondary prevention of VTE?
Background: Bridging therapy has been studied to stratify peri-procedural risk for patients with atrial fibrillation and mechanical heart valves. Data examining the necessity of post-procedural bridging for secondary prevention of VTE are lacking.
Study design: Retrospective, cohort study.
Setting: Single-state, integrated, healthcare delivery system.
Synopsis: A retrospective analysis of patients treated with warfarin for VTE prior to undergoing an invasive procedure was conducted from January 2006 through March 2012 to evaluate the occurrence of post-procedural bleeding secondary to bridging therapy, as well as the occurrence of VTE if bridging therapy was withheld.
Nearly 19,000 procedures were evaluated, of which 1,812 were included in the study. Of note, 11,710 procedures were excluded because the indication for anticoagulation was not VTE. The primary outcome was post-procedure bleeding events at 30 days, while secondary outcomes included severe bleeding events, recurrent VTE, and 30-day mortality. Patient risk of recurrent VTE was stratified into low-, medium-, and high-risk categories based on AT9 current guidelines.
Clinically relevant bleeding events occurred in 2.7% (15/555) of bridged patients and in 0.2% (2/1257) of non-bridged patients (hazard ratio of 17.2). With respect to VTE recurrence, there were three events in the non-bridged group and zero in the bridged group, which was not statistically significant (P=0.56). No VTE events were seen in the high-risk group, and there was no mortality at 30 days across any group.
Bottom line: Peri-procedural bridging therapy for VTE is associated with higher risk of bleeding, but there is not a significant risk of recurrent VTE if bridging therapy is withheld.
Citation: Clark NP, Witt DM, Davies LE, et al. Bleeding, recurrent venous thromboembolism, and mortality risks during warfarin interruption for invasive procedures. JAMA Intern Med. 2015;175(7):1163-1168. doi:10.1001/jamainternmed.2015.1843.