title: Anticoagulation bridging around device surgery: compliance with guidelines.
abstract: BACKGROUND
  Current guidelines recommend bridging anticoagulation in patients undergoing cardiac rhythm device surgery with a "moderate to high risk" of thromboembolism. Patients at "low risk" are advised to stop oral anticoagulation without bridging to the procedure. This study examines real world adherence to accepted guidelines and the clinical sequelae of nonadherence.
  
  
  METHODS
  We performed a review of all patients undergoing device surgery receiving chronic anticoagulation over a prespecified time period of 14 months. Patients were classified per American College of Chest Physician guidelines as "moderate/high risk" or "low risk" of thromboembolism. We then compared perioperative management of anticoagulation to guideline recommendations and assessed the rate of perioperative bleeding and thromboembolism.
  
  
  RESULTS
  One hundred and twenty-nine patients were included in this study. Sixty-two (48%) were classified as "moderate/high risk" and 67 (52%) "low risk." In the "moderate/high risk" group 47/62 (76%) received perioperative anticoagulation but only 25/62 (40%) were bridged both pre- and postprocedure or maintained on uninterrupted warfarin. In the "low risk" group, 22/67 (33%) received bridging therapy. Device pocket hematoma or perioperative bleeding occurred in 10/129 (8%) with 4/10 receiving inappropriate bridging for a calculated low risk of thromboembolism. There were no perioperative thromboembolisms.
  
  
  CONCLUSIONS
  Our study identified significant underutilization of bridging, particularly in the postoperative period, in patients at "moderate/high risk" of thromboembolism. Conversely, bridging was overused in "low risk" patients and associated with bleeding complications. Physicians should be urged to follow current expert guidelines in regard to bridging anticoagulation for cardiac rhythm device surgery. (PACE 2012;35:1480-1486).
authors.affiliation: Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Perrin
authors.forename: Brian Z
authors.initials: BZ
authors.lastname: Vezi
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Ha
authors.forename: Arieh
authors.initials: A
authors.lastname: Keren
authors.forename: Pablo B
authors.initials: PB
authors.lastname: Nery
authors.forename: David H
authors.initials: DH
authors.lastname: Birnie
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D058409:Cardiac Resynchronization Therapy Devices; D006348:Cardiac Surgical Procedures; D005260:Female; D019983:Guideline Adherence; D006349:Heart Valve Diseases / Q000601:surgery*; D006350:Heart Valve Prosthesis; D006495:Heparin, Low-Molecular-Weight / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013923:Thromboembolism / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight