title: Bridging therapy and oral anticoagulation: current and future prospects.
abstract: OBJECTIVE
  Patients undergoing oral anticoagulation treatment with vitamin K antagonist (VKA) therapy are at a high risk of bleeding when undergoing an invasive surgery or procedure. Bridging therapy with parenteral heparin, usually at therapeutic doses, aims to protect these patients against thromboembolism during temporary periprocedural interruption of VKA therapy. Whether or not to interrupt VKA therapy and initiate bridging therapy is a difficult decision that is based upon both the patient's and the procedure's thromboembolic and bleeding risks.
  
  
  RESULTS
  There are minor procedures that can safely be done without the need for VKA interruption. Patient groups that may benefit from bridging therapy during temporary VKA interruption for a procedure include those who are at moderate-to-high risk of thromboembolism. Procedural bleed risk should determine when to resume bridging and VKA therapies. Recent findings highlight that low-molecular-weight heparin, usually in the outpatient setting, is the preferred agent over intravenous unfractionated heparin for bridging therapy, which includes patients with prosthetic heart valve indications for VKA therapy.
  
  
  CONCLUSIONS
  Large, recently initiated placebo-controlled trials in bridging therapy are discussed, as well as future alternatives to VKA therapy in oral anticoagulation during the periprocedural period.
authors.affiliation: McMaster University, Department of Medicine, Hamilton General Hospital Thrombosis Unit, Hamilton, Ontario, Canada. spyropa@mcmaster.ca
authors.forename: Alex C
authors.initials: AC
authors.lastname: Spyropoulos
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D004334:Drug Administration Schedule; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage*; D006801:Humans; D011300:Preoperative Care; D014812:Vitamin K / Q000037:antagonists & inhibitors; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D014812:Vitamin K; D014859:Warfarin