Cardiologists, primary care physicians share in bridging anticoagulation management

A survey of clinicians in Michigan found no consensus about whether cardiologists or primary care physicians should be responsible for bridging anticoagulation management in patients with atrial fibrillation who must temporarily discontinue warfarin before undergoing a colonoscopy.

Lead researcher Geoffrey D. Barnes, MD, MSc, of the University of Michigan Health System, and colleagues published their results online in JAMA Cardiology Sept. 14.

The researchers noted that a recent study known as the Effectiveness of Bridging Anticoagulation for Surgery Trial found that the use of short-acting anticoagulants periprocedurally increased bleeding risk and did not reduce stroke risk.

In this study, researchers sent a survey to all primary care physicians, cardiologists and gastroenterologists at the University of Michigan and four other healthcare centers that participated in the Michigan anticoagulation quality improvement initiative, which Blue Cross Blue Shield of Michigan sponsored.

The clinicians received four hypothetical scenarios of patients with atrial fibrillation who are preparing for a colonoscopy and must stop using warfarin for the time being. The patients had various stroke risk factors, and the scenarios were presented in random order.

For each vignette, the clinicians were asked to indicate whether they would recommend bridging with low-molecular-weight heparin. The researchers also asked them about their experience with periprocedural anticoagulation management and who should be responsible for anticoagulation bridging decisions.

In all, 207 clinicians responded to the survey. Of the clinicians, 72.5 percent said they participated in bridging anticoagulation management at least once a month. The researchers added that cardiologists and primary care physicians had significantly different approaches to bridging.

More than 95 percent of respondents said gastroenterologists should not be responsible for making bridging decisions. The researchers found that a quarter (24.6 percent) of respondents said primary care physicians should be responsible, while 48.3 percent said cardiologists should be responsible. Further, 32.2 percent of primary care physicians said they were uncomfortable managing periprocedural anticoagulation.

“These results should encourage robust implementation efforts to standardize periprocedural anticoagulation management,” the researchers wrote. “Because periprocedural bridging is by nature complex and multidisciplinary, clinical leaders and policy makers need to assess the readiness of different specialists and support anticoagulation clinics to manage periprocedural anticoagulation.”