The effect of heparin infusion intensity on outcomes for bridging hospitalized patients with atrial fibrillation

Abstract

Background: Perioperative bridging in atrial fibrillation (AF) is associated with low thromboembolic rates but high bleeding rates. Recent guidance cautions the practice of bridging except in high risk patients. However, the practice of bridging varies widely and little data exist regarding appropriate anticoagulation intensity when using intravenous unfractionated heparin (UFH).

Hypothesis: To determine if high intensity UFH infusion regimens are associated with increased bleeding rates compared to low intensity regimens for bridging patients with AF.

Methods: We conducted a single center retrospective cohort study of admitted patients with non-valvular AF receiving UFH for ≥24 hours. UFH intensities were chosen at the providers' discretion. The primary endpoint was the rate of bleeding defined by the International Society on Thrombosis and Hemostasis during UFH infusion or within 24 hours of discontinuation. The secondary endpoint was a composite of cardiovascular events, arterial thromboembolism, venous thromboembolism, myocardial infarctions and death during UFH infusion.

Results: A total of 497 patients were included in this analysis. Warfarin was used in 82.1% and direct acting oral anticoagulants in 14.1% of patients. The rate of any bleed was higher among high intensity compared to low intensity UFH regimens (10.5% vs 4.9%, odds ratio = 2.29, 95% confidence interval = 1.07-4.90). Major bleeding was significantly higher among high intensity compared to low intensity UFH regimens. There was no difference in composite thrombotic events or death.

Conclusions: Low intensity UFH infusions, targeting lower anticoagulation targets, were associated with decreased bleeding rates without a signal of increased thromboembolic events in hospitalized AF patients.

Keywords: anticoagulation; atrial fibrillation; bleeding; bridging; heparin; thrombosis.

Figure 1

Patient cohort for primary analysis including the total number of hospitalized patients with AF on intravenous UFH infusion and reasons for exclusion. ACS, acute coronary syndrome; DVT/PE, deep vein thrombosis/pulmonary embolism; VAD, ventricular assist device. *Other: aquapheresis, congenital heart disease, carotid stent, continuous renal replacement therapy, hypercoagulable state, procedural, and heart transplant

Figure 2

Outcome (top) and pharmacokinetic (bottom) differences among high intensity vs low intensity heparin regimens. In this study, high compared to low intensity heparin regimens was associated with greater usage of bolus doses and higher infusion rates, corresponding to a significantly increased occurrence of both minor and major bleeding events without reducing thromboemboli