Anticoagulation Myth Busters

MYTH

“I need to give heparin to my patients with AF (bridging), when they are not taking warfarin or NOACs”

REALITY

“It is not uncommon for patients to undergo a planned invasive procedure or surgical intervention whilst prescribed an oral anticoagulant.

In view of the short half-life of NOACs, there is no need for bridging with LMWH – the recommendations on when to stop therapy before surgical interventions are specific to each NOAC and should be followed carefully. These recommendations can be found in the Summary of Product Characteristics for each individual NOAC.”2-5

Many minor surgical interventions may not require interruption of anticoagulation therapy. When temporary cessation of anticoagulant therapy is required, replacing oral agents with subcutaneous heparin/low molecular weight heparin (LMWH) does not seem to be beneficial, except in patients with mechanical heart valves.1 Evidence from a randomised trial of 1,884 patients with AF, demonstrated that interruption of anticoagulation was non-inferior to heparin bridging for arterial thromboembolism and resulted in a lower risk of major bleeding.1

In view of this, the general recommendation is that anticoagulant therapy in patients with AF should be withheld without bridging in patients at low risk of stroke. However, many centres do still recommend bridging with LMWH for high risk patients on warfarin, with warfarin stopped 5 days before surgery.6

REFERENCES
  1. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal. 2016;37(38):2893-962.
  2. SmPC Apixaban. medicines.org.uk: medicines.org.uk; 2019.
  3. SmPC Dabigatran. medicines.org.uk; 2019.
  4. SmPC Edoxaban. medicines.org.uk: medicines.org.uk; 2019.
  5. SmPC Rivaroxaban. medicines.org.uk: medicines.org.uk; 2019.
  6. Keeling D, Tait RC, Watson H, British Committee of Standards for H. Peri-operative management of anticoagulation and antiplatelet therapy. Br J Haematol. 2016;175(4):602-13.
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