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Anticoagulation "bridging" for patients with VTE

Posted Feb 26, 2010 at 12:50 PM, EDT by Samuel Goldhaber

Anticoagulation bridging—for a variety of reasons, from cataract surgery to teeth cleaning—is a serious and potentially risky undertaking that can provoke a number of communication issues, including errors in dosage. With little data to support the success of bridging, how can we be sure that the benefits—reducing the frequency of thrombotic events—outweigh the risk of hemorrhagic complications? When should we bridge for this type of patient?

See:

McBane RD, Wysokinski WE, Daniels PR, et al. Periprocedural anticoagulation management of patients with venous thromboembolism. Arterioscler Thromb Vasc Biol 2010; 30:442-448. Abstract.

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During that critical period when a patient is without warfarin, why not encourage the patient to be on a very low fat diet with plenty of blood thinning vegetables and fruits such as onions, garlic, ginger, celery,cucumber, papaya, pineapple, and berries are excellent for this purpose.  

In  addition, it is advisable to daily eat a half cup of high K1, dark green leafy vegetables to help regulate blood viscosity plus a 1 oz slice of imported cheese daily such as Gouda, Edam or Emmantaler which will supply K2 that will help to keep blood vessels supple. 


Posted by Isabelle Bedell.,MPH, Feb 26, 2010 at 06:17 PM, EDT
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I was wondering what you do with patients with mechanical mitral valves who need to stop for procedures: including those with concommitant afib.

Do you bridge? If so with Lovenox? or with Heparin?


Posted by Dan, Mar 01, 2010 at 10:59 AM, EDT
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In 2005, we examined the results of the failure to bridge in a-fib patients who had warfarin stopped in advance of a minor procedure (Cerebrovascular Diseases 2005;19:337-342). In our high-risk patients,  failure to either continue anticoagulation or bridge resulted in disaster in an unacceptably high number of patients.<!--EndFragment-->
Posted by Stan Cohen, Mar 01, 2010 at 12:19 PM, EDT
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We at the Jewish General Hospital Dental Dept. have been removing teeth including surgical procedures with INR up to 3 without reducing the warfarin. No bridging is done and local methods are used to stop bleeding. Cyklokapron tablets 500 mgs. are crushed and placed on wet gauze packs applied with pressure on the wound for 2 hrs. This has been extremely effective for coagulation. The use of bridging with heparin has caused uncontrolled bleeding in several oral surgical patients resulting in blood transfusions. Heparin is contra-indicated in our dept. for oral surgical procedures.
Posted by mervyn gornitsky, Mar 04, 2010 at 10:51 AM, EDT
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This comment is a reply to mervyn gornitsky (Mar 13, 2010 at 12:01 PM, EDT)

Dear Dr. Gornitsky:

 Your strategy to avoid "bridging" is an important patient safety feature.  We have encouraged dentists and oral surgeons to avoid "bridging" whenever possible.  Over time, I've noticed a trend toward more intensive local measures in the dental community rather than resorting to bridging with low molecular weight heparin.  Has the overall dental/ oral surgical community changed its way of thinking over the past decade?--SZG


Posted by Samuel Z. Goldhaber, MD, Mar 13, 2010 at 12:01 PM, EDT
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In defense of bridging...sort of.  MJ Wahl, way back in '98 reviewed 493 "valve" patients who had their anticoagulation interrupted for dental procedures.  Five had symptomatic TE events 4 of which were fatal (see  Wahl MJ, Arcxh Inern Med. 1998:1610-1616.).  Does that mean we should bridge these patients - perhaps so if we really needed to interrupt their anticoagulation.  But as discussed in several postings on ClotCare.org; interruption of anticoagulation for dental procedures is unnecessary.  If bleeding risk is substantial, the pre- and post-procedure of use of injectable Amicar as an oral rinse (also discussed on ClotCare) can prevent excessive bleeding.  Alternatively, I will always remember my patient who lost his leg because warfarin was stopped without bridging for a colonoscopy and the little old Polish lady with atrial fibrillation whose wonderful accent I will never hear again because of the disabeling stroke that resulted from no bridging for an abdominal surgery procedure.  I believe that we should carefully scrutinize the thromboembolic risk status of the patients in any study that concludes that bridging is not warranted.  My understanding of the ongoing Bridge study is that the inclusion criteria will limit the patients to moderate risk patients.  If the results indicate that bridging is not indicated in these patients, then the next step will be to repeat the study in higher risk patients; but we should not extrapolate finds in moderate risk patients to our higher risk patients.



Posted by Henry Bussey, Apr 01, 2010 at 10:12 PM, EDT
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This comment has been removed
Amicar comes as an elixir for oral use and in tablet form.  In our experience, however, the 5 gm vial for injection is much less expensive than the elixir and it is a sterile product which can be diluted with sterile water for injection right before use.
Posted by Henry Bussey, Pharm.D., Feb 21, 2011 at 12:43 AM, EDT
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