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Safety and Efficacy of Bridging with Low Molecular Weight Heparins: A Systematic Review and Partial Meta-Analysis

[ Vol. 19 , Issue. 22 ]


Pieter Eijgenraam, Hugo ten Cate and Arina ten Cate-Hoek   Pages 4014 - 4023 ( 10 )


Background: Surgical interventions in patients on long term vitamin K antagonist (VKA) treatment create a dilemma; periprocedural interruption of anticoagulation raises the risk of thrombosis, while continuation raises the risk of bleeding. The anticoagulation- free interval is minimized by “bridging” with parenteral anticoagulants. The efficacy and safety of bridging with low molecular weight heparins (LMWH) has however not been unequivocally established.

Methods: We performed an EMBASE and MEDLINE search for studies that compared bridging anticoagulation with continuation or cessation of VKA without bridging; with thromboembolism (TE) and bleeding as outcomes. We identified 878 articles and finally selected 17. Results of individual studies were pooled.

Results: None of the included studies reported significant differences in incidence of TEs between the bridging group and the comparator group; 4 out of 13 studies reported zero TEs. Heparin was identified as a risk factor for bleeding in multivariable adjusted analyses in 3 studies on pacemaker/implantable cardioverter defibrillator (PM/ICD) surgery. In 5 studies (different types of surgery) with unadjusted analyses, bridging was compared to warfarin cessation: 3 studies reported null results for bleeding; 2 studies identified bridging as a risk factor. We pooled a subset of 6 studies regarding postoperative bleeding after PM/ICD surgery and found a relative risk (RR) of 3.03 (95% confidence interval (CI), 1.86-4.95) for bridging compared to continuation of VKA.

Conclusions: While the antithrombotic efficacy of bridging with LMWH has not been demonstrated, increased bleeding risk is observed in different types of surgery. PM/ICD surgery can be safely performed on continued VKA.


Thrombosis, bleeding, systematic review, surgery, anticoagulants, vitamin K antagonists, low molecular weight heparins.


Department of Internal Medicine, laboratory of Clinical Thrombosis and Hemostasis, Maastricht University Medical Centre+, PO Box 616, 6200 MD Maastricht, The Netherlands.

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