Hold or Bridge?

[Marty]

As I have noted here in earlier posts, the physicians I work with prefer to "hold" rather than bridge prior to colonoscopy, and other procedures. Here is some evidence supporting them. My cardiologist says that in all his years of practise he has had no problems.

Dangers of Interrupting Warfarin Therapy Weighed

Warfarin therapy may be interrupted with low risk for as long as 5 days for
minor invasive procedures, but vigilance is required, the Archives of Internal
Medicine reports.

Industry-funded researchers prospectively evaluated outcomes in some 1000
patients whose warfarin therapy was interrupted, most often for 5 days or fewer
and to accommodate requirements for colonoscopy or oral/dental surgery. Bridging
therapy (perioperative heparin) was used in less than 10% of cases.

Seven patients (less than 1%) suffered thromboembolism within 30 days of the
procedure; none had received bridging therapy. Of the 23 patients who had
bleeding episodes within 30 days, nearly two-thirds had received bridging
therapy.

The authors conclude that, until a trial of bridging versus nonbridging therapy
is performed, physicians may use these results to "weigh the risks and benefits
of different perioperative treatment strategies for patients taking warfarin."

Link(s):
Archives of Internal Medicine article (Free abstract; full text requires
subscription) http://click.jwatch.org/cts/click?

 

[geebee]

I sure would be curious as to how much damage was done by the clots and the bleeding. Also, are we to assume that those who were bridged had no clotting issues (therefore the bridging worked). Without really knowing how bad the bleeding was or how much damage the clot caused, it's kind of hard to make any decisions based on this study.

 

[Nancy]

I guess I have mixed feeling. When Joe got to the 65 years of age level or so, he started getting funky reactions to Heparin and Lovenox, such as it causing heavy bleeding. He did not have Heparin Induced Thrombocytopenia (HIT) and was tested several times. It was just his system which started to become overreactive to many things. Heparin was much better than Lovenox, but then he had to be hospitalized for that.

I think that is something to discuss with your doc, Marty.

You are in much better shape medically than Joe was, I am sure, so perhaps it isn't something you would have to worry about. But I did want to mention it.

 

[ALCapshaw2]

I've asked several Cardio-Thoracic Surgeons I've known or met about their philosophy on Bridging.

One simply stops Coumadin 5 days before surgery and resumes that night after surgery (although he stated he would be willing to use whatever protocol *I* desired...eek! I know the options, but how do *I* make the call on when to resume *after* surgery, i.e. how do I assess the Bleeding Risk vs. the Stroke Risk???)

Another uses Lovenox, before and after.

Another uses Lovenox before and Heparin Drip after (since you will still be in the Hospital)

Another uses Lovenox before and simply resumes Coumadin that night, following surgery.

That's 4 surgeons and 4 protocols!
Does this go on forever??? ;-)

My GastroEnterologist refused to proceed with a combined Colonoscopy and Upper Endoscopy until I was OFF my Coumadin, just in case he would need to remove polyps or decide to take a biopsy. He did agree to Bridging which was managed by the CRNP at my Coumadin Clinic with concurrence of the GI Doc and my Cardio.

Obviously there is NO Single Standard!

'AL Capshaw'

 

[warrenr]

bridging

bridging

Don't forget that there is another option. Depending on the type of procedure the other option is to have the procedure conducted fully anticoagulated or a monitored reduction of anticoagulation.

Another thing to keep in mind: The majority of valve replacements are aortic valves which carry a lower risk of thrombus and stroke compared to mitral valve. In order to properly stratify the risk of stopping coumadin/warfarin one must take valve position into consideration along with other existing conditions such as afib, lv disfunction, etc. In almost all of the documents I have researched, mechanical aortic valve (with no other pre-existing conditions) is a low risk condition for stopping coumadin/warfarin for several day's and mechanical mitral valve is a high risk condition for stopping coumadin/warfarin.

When having a procedure such as colonoscopy, dental procedure, mole removal, etc. you must stratify the procedure into low risk of bleeding or high risk of bleeding. Keep in mind that the vast majority of these procedures are Elective and many of them are considered low bleed risk procedures.

What happens in a lot of these cases is that the physician either tells you to stop coumadin/warfarin with bridging or tells you to stop coumadin/warfarin period. It seems they don't consider the fully anticoagulated or monitored dose reduction stradegy which is what they should be doing for low bleed risk procedure regardless of valve position.

below is a good link concerning dental procedures:
http://jada.ada.org/cgi/content/full/131/1/77

 

[Ross]

I have a dream. My dream is this, we get EVERY Physician into a world summit on anticoagulation therapy. The only way these guys are ever going to learn is if it's done in some such manor. Some of the new kids coming out of NEOCOM here in Ohio actually have a greater understanding of Coumadin then their professors do and yes, the professors are still teaching myth. I would love for something like this to happen before I die. Is it possible?

 

[ALCapshaw2]

I sure would be curious as to how much damage was done by the clots and the bleeding. Also, are we to assume that those who were bridged had no clotting issues (therefore the bridging worked). Without really knowing how bad the bleeding was or how much damage the clot caused, it's kind of hard to make any decisions based on this study.

You raised some VERY GOOD POINTS Gina !

I went to a General Surgeon that my GI Doc likes to refer his patients to to have him lance an infected cyst. To my surprise and delight, he understoond the Stroke Risk vs. Bleeding Risk and was willing to proceed fully anti-coagulated. The initial surgery had some bleeding but nothing excessive.

He did some cauterizing, packed the opening (about 1 square inch under my arm) and told me to keep pressure on it for a few hours. It continued to seep into the bandage when pressure was relieved. The first re-packing at home went well.

The next day I went to a nearby Urgent Care facility for a separate issue and asked the Doc to check my incision. It bled all over the examing table and floor. He repacked it and applied a Pressure Bandage which worked much better than the gause and regular tape bandage used by the surgeon.

The surgeon agreed to do my next repacking. I bled on his White Coat (and the table and the floor). He applied ONE stitch, did some more cauterizing, and repacked the incision. From that point on, we were able to repack daily at home until the wound was completely healed.

I hope that there aren't any Doctors who consider bleeding on their White Coats (and examing tables and floor) equal to the damage of a STROKE to the Patient!

'AL Capshaw'

 

[Rich]

I have had both colonoscopy and endoscopy while fully anti-coagulated.
My gastro guy is one of the few who seems to have a handle on this(and he is not young either).
He had them run a quick blood test before each procedure to see just where my INR was at.
For the colon job he removed five polyps and there was never a problem. During that time my INR was around 2.4.
And as we have all discussed before, if there is something major to be done, then we will go back a second time with bridging or whatever.
I was really concerned about my nieghbor. He takes coumadin because of a-fib. When he went for these two procedures, his doctor insisted on stopping it five days prior AND five days after. What a dumbbell!!
Rich

 

[Marty]

Frankly,Rich, I think this is the best course of action. For minor procedures, go ahhead anticoagulated with INR about 2.5. No holding, no bridging.(KISS) A few years ago I had a skin biopsy for a mole and then the dermatologist had to go back and take out a big ellipse because it was malignant melanoma. No hematoma or infection after. Can hardly see scar.