Perioperative Management in Patients Using Vitamin K Antagonists: Observational Cohort Study

BACKGROUND: The benefit of periprocedural bridging with low-molecular-weight heparin (LMWH) in patients with atrial fibrillation has been contested by the publication of the BRIDGE trial. OBJECTIVE: This article determines whether publication of the BRIDGE trial has led to less bridging procedures and better patient outcomes (i.e., a composite of thromboembolism, major bleeding, and death) in patients undergoing invasive procedures at the Leiden Anticoagulation Clinic, the Netherlands. METHODS: We identified all procedures that required vitamin K antagonist interruption. Procedures were divided in a period before (2014-2016; 22 months) and after the publication of the BRIDGE trial (2016-2017; 22 months). Cumulative incidences 30 days postprocedure and relative risks of thromboembolic events, major bleeding, and mortality were calculated. RESULTS: A total of 4,892 and 4,237 eligible procedures were performed in 2014 to 2016 and 2016 to 2017, respectively. The cumulative incidence of thromboembolism was 0.5% in 2014 to 2016 compared with 0.3% in 2016 to 2017; adjusted odds ratio (OR) 0.60 (95% confidence interval [CI] 0.30-1.21). The cumulative incidence of major bleeding was 1.0% in the 2014 to 2016 period as compared with 1.3% in the 2016 to 2017 period; adjusted OR was 1.27 (95% CI 0.85-1.90). The adjusted OR of the composite endpoint was 1.05 (95% CI 0.74-1.48). The frequency of bridging with LMWH (14.8% in 2014-2016 vs. 16.6% in 2016-2017) as well as mean CHA2DS2-VASc scores of patients receiving bridging did not change after publication of the BRIDGE trial. CONCLUSION: We showed that despite publication of the BRIDGE trial, the frequency of bridging with LMWH and patient outcomes regarding bleeding complications did not change.