title: Low-molecular-weight-heparins as periprocedural anticoagulation for patients on long-term warfarin therapy: a standardized bridging therapy protocol.
abstract: BACKGROUND
  Over 2 million patients in North America are on warfarin anticoagulation therapy for prevention of thromboembolism. Suspension of warfarin therapy is often required to prepare patients for invasive procedures or surgeries. To protect these patients against thromboembolism while they are off warfarin, shorter-acting parenteral agents such as low-molecular-weight heparins (LMWHs) are often used. We conducted a retrospective observational study of our anticoagulation clinic patients to assess the safety and efficacy of LMWHs using a standardized protocol for periprocedural anticoagulation therapy.
  
  
  METHODS
  We included 69 consecutive patients who required interruption of their long-term warfarin therapy between August 2001 and August 2002, and were deemed by the treating physician to be at high enough risk for perioperative thromboembolism to justify bridging anticoagulation. We used a standard bridging therapy protocol in our anticoagulation clinic. Sixty-six patients received enoxaparin and three patients received tinzaparin for a mean duration of 7.7 days postoperatively. Outcomes were assessed for 30 days post-procedure. Safety outcomes included major bleeding and minor bleeding. Efficacy outcomes included thromboembolic event or death.
  
  
  RESULTS
  There were two major bleeding events, one minor bleeding event, and no cases of thromboembolism. Twelve patients experienced some bruising around the injection site.
  
  
  CONCLUSIONS
  LMWH administration using our standard outpatient bridging protocol for perioperative anticoagulation appears to be relatively safe and efficacious, offering an alternative to inpatient administration of intravenous unfractionated heparin (UFH). Our study provides additional evidence to the limited published observational data regarding the safety and efficacy of LMWH as bridging therapy in the perioperative and periprocedural setting. Large, multicenter, randomized controlled trials are necessary to fully assess the safety and efficacy of LMWH for perioperative anticoagulation.We conducted a retrospective observational study of 69 consecutive anticoagulation clinic patients on warfarin between August 2001 and August 2002, who were undergoing a procedure or surgery. The study was done to assess the safety and efficacy of an outpatient LMWH bridging protocol. Sixty-six patients received enoxaparin and three patients received tinzaparin for a mean duration of 3 days preoperatively and 7.7 days postoperatively. Outcomes were assessed for 30 days post-procedure. Safety outcomes included major bleeding and minor bleeding. Efficacy outcomes included thromboembolic event or death. There were two major bleeding events, one minor bleeding event, and no cases of thromboembolism. Twelve patients experienced some bruising around the injection site.
authors.affiliation: Section of Hospital Medicine, IMPACT Investigators Group, Cleveland Clinic Foundation, 9500 Euclid Ave, Desk A72, Clevaland 44195, OH, USA. jaffera@ccf.org
authors.forename: Amir K
authors.initials: AK
authors.lastname: Jaffer
authors.forename: Mudassar
authors.initials: M
authors.lastname: Ahmed
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Brotman
authors.forename: Lee
authors.initials: L
authors.lastname: Bragg
authors.forename: Niranjan
authors.initials: N
authors.lastname: Seshadri
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Qadeer
authors.forename: Allan
authors.initials: A
authors.lastname: Klein
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy; D017984:Enoxaparin / Q000627:therapeutic use; D005260:Female; D006350:Heart Valve Prosthesis; D006470:Hemorrhage / Q000209:etiology; D006495:Heparin, Low-Molecular-Weight / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012189:Retrospective Studies; D020521:Stroke / Q000453:epidemiology; D013923:Thromboembolism / Q000517:prevention & control; D000078222:Tinzaparin; D014859:Warfarin / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin; D006495:Heparin, Low-Molecular-Weight; D014859:Warfarin; D000078222:Tinzaparin