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Safety and Efficacy of Bridging with Low-Molecular-Weight Heparin during Temporary Interruptions of Warfarin : A Register-Based Cohort Study

Sjögren, Vilhelm; Grzymala-Lubanski, Bartosz; Renlund, Henrik; Svensson, Peter J. LU and Själander, Anders (2017) In Clinical and Applied Thrombosis/Hemostasis 23(8). p.961-966
Abstract

Low-molecular-weight heparin (LMWH) is often recommended as a bridging therapy during temporary interruptions in warfarin treatment, despite lack of evidence. The aim of this study was to see whether we could find benefit from LMWH bridging. We studied all planned interruptions of warfarin within the Swedish anticoagulation register Auricula during 2006 to 2011. Low-molecular-weight heparin bridging was compared to nonbridging (control) after propensity score matching. Complications were identified in national clinical registers for 30 days following warfarin cessation, and defined as all-cause mortality, bleeding (intracranial, gastrointestinal, or other), or thrombosis (ischemic stroke or systemic embolism, venous thromboembolism, or... (More)

Low-molecular-weight heparin (LMWH) is often recommended as a bridging therapy during temporary interruptions in warfarin treatment, despite lack of evidence. The aim of this study was to see whether we could find benefit from LMWH bridging. We studied all planned interruptions of warfarin within the Swedish anticoagulation register Auricula during 2006 to 2011. Low-molecular-weight heparin bridging was compared to nonbridging (control) after propensity score matching. Complications were identified in national clinical registers for 30 days following warfarin cessation, and defined as all-cause mortality, bleeding (intracranial, gastrointestinal, or other), or thrombosis (ischemic stroke or systemic embolism, venous thromboembolism, or myocardial infarction) that was fatal or required hospital care. Of the 14 556 identified warfarin interruptions, 12 659 with a known medical background had a mean age of 69 years, 61% were males, mean CHADS2 (1 point for each of congestive heart failure, hypertension, age ≥75 years, diabetes, and 2 points for stroke or transient ischemic attack) score was 1.7, and CHA2DS2-VASc score was 3.4. The total number of LMWH bridgings was 7021. Major indications for anticoagulation were mechanical heart valve prostheses 4331, atrial fibrillation 1097, and venous thromboembolism 1331. Bridging patients had a higher rate of thrombotic events overall. Total risk of any complication did not differ significantly between bridging (1.5%) and nonbridging (1.2%). Regardless of indication for warfarin treatment, we found no benefit from bridging. The type of procedure prompting bridging was not known, and the likely reason for the observed higher risk of thrombosis with LMWH bridging is that low-risk procedures more often meant no bridging. Results from randomized trials are needed, especially for patients with mechanical heart valves.

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author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
bridging, dalteparin, enoxaparin, low-molecular-weight heparin, tinzaparin, warfarin
in
Clinical and Applied Thrombosis/Hemostasis
volume
23
issue
8
pages
6 pages
publisher
SAGE Publications Inc.
external identifiers
  • scopus:85031327105
  • wos:000412901900009
ISSN
1076-0296
DOI
10.1177/1076029617706756
language
English
LU publication?
yes
id
8e4e3e93-62ec-4c82-ae33-02c7f4533920
date added to LUP
2017-10-24 10:19:43
date last changed
2018-04-15 04:48:11
@article{8e4e3e93-62ec-4c82-ae33-02c7f4533920,
  abstract     = {<p>Low-molecular-weight heparin (LMWH) is often recommended as a bridging therapy during temporary interruptions in warfarin treatment, despite lack of evidence. The aim of this study was to see whether we could find benefit from LMWH bridging. We studied all planned interruptions of warfarin within the Swedish anticoagulation register Auricula during 2006 to 2011. Low-molecular-weight heparin bridging was compared to nonbridging (control) after propensity score matching. Complications were identified in national clinical registers for 30 days following warfarin cessation, and defined as all-cause mortality, bleeding (intracranial, gastrointestinal, or other), or thrombosis (ischemic stroke or systemic embolism, venous thromboembolism, or myocardial infarction) that was fatal or required hospital care. Of the 14 556 identified warfarin interruptions, 12 659 with a known medical background had a mean age of 69 years, 61% were males, mean CHADS<sub>2</sub> (1 point for each of congestive heart failure, hypertension, age ≥75 years, diabetes, and 2 points for stroke or transient ischemic attack) score was 1.7, and CHA<sub>2</sub>DS<sub>2</sub>-VASc score was 3.4. The total number of LMWH bridgings was 7021. Major indications for anticoagulation were mechanical heart valve prostheses 4331, atrial fibrillation 1097, and venous thromboembolism 1331. Bridging patients had a higher rate of thrombotic events overall. Total risk of any complication did not differ significantly between bridging (1.5%) and nonbridging (1.2%). Regardless of indication for warfarin treatment, we found no benefit from bridging. The type of procedure prompting bridging was not known, and the likely reason for the observed higher risk of thrombosis with LMWH bridging is that low-risk procedures more often meant no bridging. Results from randomized trials are needed, especially for patients with mechanical heart valves.</p>},
  author       = {Sjögren, Vilhelm and Grzymala-Lubanski, Bartosz and Renlund, Henrik and Svensson, Peter J. and Själander, Anders},
  issn         = {1076-0296},
  keyword      = {bridging,dalteparin,enoxaparin,low-molecular-weight heparin,tinzaparin,warfarin},
  language     = {eng},
  month        = {11},
  number       = {8},
  pages        = {961--966},
  publisher    = {SAGE Publications Inc.},
  series       = {Clinical and Applied Thrombosis/Hemostasis},
  title        = {Safety and Efficacy of Bridging with Low-Molecular-Weight Heparin during Temporary Interruptions of Warfarin : A Register-Based Cohort Study},
  url          = {http://dx.doi.org/10.1177/1076029617706756},
  volume       = {23},
  year         = {2017},
}