title: Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF).
abstract: BACKGROUND
  Temporary interruption of oral anticoagulation for procedures is often required, and some propose using bridging anticoagulation. However, the use and outcomes of bridging during oral anticoagulation interruptions in clinical practice are unknown.
  
  
  RESULTS
  The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry is a prospective, observational registry study of US outpatients with atrial fibrillation. We recorded incident temporary interruptions of oral anticoagulation for a procedure, including the use and type of bridging therapy. Outcomes included multivariable-adjusted rates of myocardial infarction, stroke or systemic embolism, major bleeding, cause-specific hospitalization, and death within 30 days. Of 7372 patients treated with oral anticoagulation, 2803 overall interruption events occurred in 2200 patients (30%) at a median follow-up of 2 years. Bridging anticoagulants were used in 24% (n=665), predominantly low-molecular-weight heparin (73%, n=487) and unfractionated heparin (15%, n=97). Bridged patients were more likely to have had prior cerebrovascular events (22% versus 15%; P=0.0003) and mechanical valve replacements (9.6% versus 2.4%; P<0.0001); however, there was no difference in CHA2DS2-VASc scores (scores ≥ 2 in 94% versus 95%; P=0.5). Bleeding events were more common in bridged than nonbridged patients (5.0% versus 1.3%; adjusted odds ratio, 3.84; P<0.0001). The incidence of myocardial infarction, stroke or systemic embolism, major bleeding, hospitalization, or death within 30 days was also significantly higher in patients receiving bridging (13% versus 6.3%; adjusted odds ratio, 1.94; P=0.0001).
  
  
  CONCLUSIONS
  Bridging anticoagulation is used in one quarter of anticoagulation interruptions and is associated with higher risk for bleeding and adverse events. These data do not support the use of routine bridging, and additional data are needed to identify best practices concerning anticoagulation interruptions.
  
  
  BACKGROUND
  http://www.clinicaltrials.gov. Unique identifier: NCT01165710.
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.). benjamin.steinberg@duke.edu.
authors.forename: Benjamin A
authors.initials: BA
authors.lastname: Steinberg
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Sunghee
authors.initials: S
authors.lastname: Kim
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Laine
authors.initials: L
authors.lastname: Thomas
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Bernard J
authors.initials: BJ
authors.lastname: Gersh
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Peter R
authors.initials: PR
authors.lastname: Kowey
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Sherwood
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Paul
authors.initials: P
authors.lastname: Chang
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Piccini
authors.affiliation: From the Duke University Medical Center, Durham, NC (B.A.S., E.D.P., M.W.S., J.P.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., E.D.P., S.K., L.T., M.W.S., J.P.P.); Mayo Clinic, Rochester, MN (B.J.G.); UCLA Division of Cardiology, Los Angeles, CA (G.C.F.); Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.); Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); Janssen Scientific Affairs, Raritan, NJ (P.C.); and New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.).
authors.forename: Jack
authors.initials: J
authors.lastname: Ansell
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects*; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology; D015331:Cohort Studies; D004334:Drug Administration Schedule; D005260:Female; D005500:Follow-Up Studies; D006470:Hemorrhage / Q000139:chemically induced / Q000175:diagnosis / Q000453:epidemiology; D006801:Humans; D008297:Male; D011446:Prospective Studies; D012042:Registries; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants
keywords: anticoagulants; atrial fibrillation; outcome assessment (health care)