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(HealthNewsDigest.com) – Atrial fibrillation, an irregular and sometimes rapid heart rate that causes poor blood circulation, affects approximately 3 million people in the United States. Because they are at a higher risk for blood clots that can cause a stroke, people with atrial fibrillation often are given a blood thinner such as warfarin for long-term use.
If these patients need surgery or a procedure, they receive a shorter-acting blood thinner such as injectable heparin before and after the procedure to prevent blood clots from forming. Doctors have highly recommended this protocol, called bridge therapy, but results from a research study published June 22 in the New England Journal of Medicine raises questions about this longstanding practice.
“This study shows no benefit of bridge therapy, but rather highlights that it causes increased major bleeding and is therefore harmful,” says study co-author Amir K Jaffer, MD, MBA, professor of medicine, associate chief medical officer and vice chair of quality and patient safety at Rush.
Funded by the National Heart, Lung and Blood Institute of the National Institutes of Health, the study included 1,884 patients at 108 sites in the U.S. and Canada, including Rush. The site investigators at Rush also included Stuart Rosenbush, MD, and Annabelle Volgman, MD. To help understand atrial fibrillation and bridging therapy, Jaffer here answers questions about the study, which was the first large randomized clinical trial to examine if bridge therapy is needed.
What did your study examine?
The study enrolled nearly 1,900 patients who were taking warfarin for atrial fibrillation and needed surgery or a procedure. All of them stopped taking warfarin five days before their procedure, and were divided into two groups. About half received bridge therapy before and after the surgery, and the other half received a placebo during the same general time period. Both groups also resumed warfarin treatment within 24 hours after their procedure. The investigators followed up with the patients for 30 days after their surgery to see if there was a difference in the incidence of blood clots and major bleeding between the groups.
What did you find?
There was no significant difference in strokes. The placebo group had a rate of 0.4 percent vs.0.3 percent for the bridge therapy group. On the other hand, the amount of major bleeding after surgery for the group that received bridge therapy was 3.2 percent, much greater than the 1.3 percent for the group that received the placebo. It was noted that the bleed occurred usually during the time there was overlap of blood thinners. Given this data, we concluded that not using bridge therapy decreases the risk of major bleeding without increasing the risk of stroke.
Does this mean physicians should change the current treatment right away?
Physicians definitely need to change their practice for many atrial fibrillation patients, especially those with stroke risk (CHADS2) scores between 0 and 4. Many patients with atrial fibrillation could have their warfarin discontinued for surgery or a procedure without taking bridging therapy. This paper will definitely change practice around the management of these patients and the current recommended guidelines around the management of these patients.
How many people receive bridge therapy?
A lot. There are currently nearly 3 million patients who are taking anticoagulants including warfarin to prevent stroke, which is the most feared complication of atrial fibrillation. Approximately one in six of these patients need a surgery or procedure each year, which usually requires cessation of warfarin therapy, which is long-acting. Instead, patients receive a shorter-acting kind of anticoagulant called heparin.
Why are these patients given bridge therapy?
When atrial fibrillation patients need surgery or a procedure that can cause too much bleeding, doctors are faced with the dilemma of whether to just stop the blood thinner, warfarin, or to give another blood thinner such as heparin that can be stopped and started in a much quicker fashion.
Doctors differed in the way they approached this dilemma since until now there was never a study to examine whether it was important to “bridge” the blood thinning from the long acting drug, to the short acting drug.
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