Circling back to ORBIT-AF: Bridging anticoagulation may increase bleeding, adverse events risk

Before you cross that bridge, consider: A fresh look at the data from ORBIT-AF suggests that bridging oral anticoagulation instead of temporary cessation for a procedure may put patients at greater risk for bleeding or adverse events.

Researchers delved into observational data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF), to look at real-world trends. Data in ORBIT-AF reflects a national outpatient population sampling of primary care, cardiology and/or electrophysiology patients with atrial fibrillation. This recent iteration of ORBIT-AF’s findings was published online Dec. 12 in Circulation.

Benjamin A. Steinberg, MD, MHS, from the Duke University Medical Center in Durham, N.C., and colleagues used ORBIT-AF follow-up data through two years for their assessment.

Among 2,200 patients for whom oral anticoagulation was stopped before a procedure, nearly one quarter were given bridging anticoagulation. While no difference was reported in CHA2DS2-VASc scores between those who were and were not given bridging anticoagulation, patients who received bridging anticoagulation were more likely to have had prior cerebrovascular events or mechanical valve replacements.

However, they noted rates of MI, systemic embolism, major bleeding, hospitalization or death within 30-days were about double in patients receiving bridging anticoagulation (13 percent vs. 6.3 percent). Bleeding was also more common, occurring in 5 percent of bridged patients as opposed to 1.3 percent of those who remained unbridged.

Patients who had been bridged were twice as likely to have any adverse event. Major bleeding occurred in 3.6 percent of bridged patients as opposed to 1.2 percent of unbridged patients. Hospitalizations due to bleeding occurred at a rate of 2.2 percent and 0.7 percent among bridged and unbridged patients, respectively. Hospitalizations from cardiovascular events were nearly double: 4.2 percent and 2.2 percent for bridged and unbridged patients, respectively. They calculated the odds for bleeding events around 3.84 and for cardiovascular events around 1.62 for patients whose anticoagulation was bridged.

Notably, while the type of procedure precipitating the interruption in anticoagulation did not appear to influence composite outcomes, they found that adverse events were less common for dental procedures, which accounted for 9 percent of interruptions overall, many of which were bridged procedures.

Steinberg et al wrote that the use of bridging appeared to reflect limited guideline support, however room still existed for improvement. They noted that bridging in the community generally lacks the same rigorous protocols of clinical trials, which may also influence the outcomes seen in this assessment.

“Properly identifying the group of patients, if any, in whom the risk of these pitfalls is outweighed by the benefit of OAC [oral anticoagulation] interruption and bridging remains a challenge,” Steinberg et al wrote.

Amir Y. Shaikh, MD, from the University of Massachusetts Medical School in Worcester, and colleagues commented in an editorial that understanding the correct patient population for this method was important, but that physicians themselves already had the answer. “Continue to utilize the 3-tier risk stratification system proposed by the ACCP [American College of Clinical Pharmacy], which includes procedure type and duration as important contributors to per-procedural bleeding risk,” Shaikh et al wrote.

Steinberg et al and Shaikh et al agreed further research into this topic was important to better control bleeding and adverse events among patients requiring anticoagulation.