Effects of heparinoid bridging in patients with mechanical heart valves.
Journal
Journal of the American Association of Nurse Practitioners
ISSN: 2327-6924
Titre abrégé: J Am Assoc Nurse Pract
Pays: United States
ID NLM: 101600770
Informations de publication
Date de publication:
16 Nov 2020
16 Nov 2020
Historique:
received:
15
08
2020
accepted:
21
09
2020
pubmed:
20
11
2020
medline:
15
12
2021
entrez:
19
11
2020
Statut:
epublish
Résumé
Patients with mechanical heart valves (MHVs) require long-term oral anticoagulation therapy to protect against thromboembolisms. Invasive procedures with high bleeding risks require oral anticoagulation therapy cessation. Currently, guidelines recommend the use of either subcutaneous low-molecular-weight heparin or intravenous unfractionated heparin in the perioperative period. It is unclear whether the evidence supports the use of one heparinoid over the other. To compare the effectiveness of low-molecular-weight heparin and unfractionated heparin bridging based on the adverse outcomes of thromboembolisms, major bleeding, and death during the perioperative period. A literature search was conducted using PubMed, EMBASE, CINAHL, and the Cochrane Library. Five studies comparing the two bridging therapies in chronically anticoagulated MHV patients met the inclusion criteria. No statistical significance was found for the endpoints of thromboembolism and death. One study found a statistically significant higher occurrence of major bleeding in patients treated with unfractionated heparin. In all the studies, major bleeding occurred more often than thromboembolisms. Findings were limited by the study designs and methodologies. Based on the available evidence, neither low-molecular-weight heparin nor intravenous heparin bridging was found to be more effective in reducing the occurrence of adverse events. This may be due in part to the study designs and lack of standardized bridging protocols used in the studies reviewed. Nurse practitioners should remain informed about bridging protocols and weigh the risk versus benefit of each bridging agent when caring for patients with MHVs.
Sections du résumé
BACKGROUND
BACKGROUND
Patients with mechanical heart valves (MHVs) require long-term oral anticoagulation therapy to protect against thromboembolisms. Invasive procedures with high bleeding risks require oral anticoagulation therapy cessation. Currently, guidelines recommend the use of either subcutaneous low-molecular-weight heparin or intravenous unfractionated heparin in the perioperative period. It is unclear whether the evidence supports the use of one heparinoid over the other.
OBJECTIVES
OBJECTIVE
To compare the effectiveness of low-molecular-weight heparin and unfractionated heparin bridging based on the adverse outcomes of thromboembolisms, major bleeding, and death during the perioperative period.
DATE SOURCES
METHODS
A literature search was conducted using PubMed, EMBASE, CINAHL, and the Cochrane Library. Five studies comparing the two bridging therapies in chronically anticoagulated MHV patients met the inclusion criteria.
CONCLUSIONS
CONCLUSIONS
No statistical significance was found for the endpoints of thromboembolism and death. One study found a statistically significant higher occurrence of major bleeding in patients treated with unfractionated heparin. In all the studies, major bleeding occurred more often than thromboembolisms. Findings were limited by the study designs and methodologies.
IMPLICATIONS FOR PRACTICE
CONCLUSIONS
Based on the available evidence, neither low-molecular-weight heparin nor intravenous heparin bridging was found to be more effective in reducing the occurrence of adverse events. This may be due in part to the study designs and lack of standardized bridging protocols used in the studies reviewed. Nurse practitioners should remain informed about bridging protocols and weigh the risk versus benefit of each bridging agent when caring for patients with MHVs.
Identifiants
pubmed: 33208608
pii: 01741002-202112000-00008
doi: 10.1097/JXX.0000000000000537
doi:
Substances chimiques
Anticoagulants
0
Heparin, Low-Molecular-Weight
0
Heparinoids
0
Heparin
9005-49-6
Types de publication
Journal Article
Review
Langues
eng
Pagination
1148-1155Informations de copyright
Copyright © 2020 American Association of Nurse Practitioners.
Déclaration de conflit d'intérêts
Competing interests: The author reports no conflicts of interest.
Références
Attaya H., Shah N. D., Wysokinski W. E., Van Houten H. K., Heit J. A., McBane R. D. II. (2013). Outcomes and total costs of outpatient vs. inpatient peri-procedural anticoagulation management of mechanical prosthetic heart valve patients. International Journal of Cardiology, 168, 5311–5315. https://doi.org/10.1016/j.ijcard.2013.08.010.
doi: 10.1016/j.ijcard.2013.08.010
Daniels P. R., McBane R. D., Litin S. C., Ward S. A., Hodge D. O., Dowling N. F., Heit J. A. (2009). Peri-procedural anticoagulation management of mechanical prosthetic heart valve patients. Thrombosis Research, 124, 300–305. https://doi.org/10.1016/j.thromres.2009.01.011.
doi: 10.1016/j.thromres.2009.01.011
Douketis J., Lip G. Y. (2019). Perioperative management of patients receiving anticoagulants. UpToDate. Retrieved from https://www.uptodate.com/contents/perioperative-management-of-patients-receiving-anticoagulants.
Hart E. A., Jansen R., Meijs T. A., Bouma B. J., Riezebos R. K., Tanis W., van Boven W., Hindori V., Wiersma N., Dessing T., Westerink J., Chamuleau S. A. J. (2017). Anticoagulant bridging in left-sided mechanical heart valve patients. International Journal of Cardiology, 232, 121–126. https://doi.org/10.1016/j.ijcard.2017.01.042.
doi: 10.1016/j.ijcard.2017.01.042
Hirsh J., Anand S. S., Halperin J. L., Fuster V. (2001). Mechanism of action and pharmacology of unfractionated heparin. Arteriosclerosis, Thrombosis, and Vascular Biology, 21, 1094–1096. https://doi.org/10.1161/hq0701.093686.
doi: 10.1161/hq0701.093686
Hull R. D., Garcia D. A., Burnett A. E. (2019). Heparin and LMW heparin: Dosing and adverse effects. UpToDate. Retrieved from https://www.uptodate.com/contents/heparin-and-lmw-heparin-dosing-and-adverse-effects.
Lyaker M. R., Tulman D. B., Dimitrova G. T., Pin R. H., Papadimos T. J. (2013). Arterial embolism. International Journal of Critical Illness and Injury Science, 3, 77–87. https://doi.org/10.4103/2229-5151.109429.
doi: 10.4103/2229-5151.109429
Nishimura R. A., Otto C. M., Bonow R. O., Carabello B. A., Erwin J. P. III, Fleisher L. A., Jneid H., Mack M. J., McLeod C. J., O'Gara P. T., Rigolin V. H., Sundt T. M. III, Thompson A. (2017). 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Journal of the American College of Cardiology, 70, 252–289. https://doi.org/S0735-1097(17)36019-9.
doi: S0735-1097(17)36019-9
Spyropoulos A. C., Turpie A. G., Dunn A. S., Kaatz S., Douketis J., Jacobson A., Petersen H. (2008). Perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin in patients with mechanical prosthetic heart valves on long-term oral anticoagulants (from the REGIMEN Registry). The American Journal of Cardiology, 102, 883–889. https://doi.org/10.1016/j.amjcard.2008.05.042.
doi: 10.1016/j.amjcard.2008.05.042
Tafur A. J., McBane R. II, Wysokinski W. E., Litin S., Daniels P., Slusser J., Hodge D., Beckman M. G., Heit J. A. (2012). Predictors of major bleeding in peri-procedural anticoagulation management. Journal of Thrombosis and Haemostasis: JTH, 10, 261–267. https://doi.org/10.1111/j.1538-7836.2011.04572.x.
doi: 10.1111/j.1538-7836.2011.04572.x
Tan C. W., Wall M., Rosengart T. K., Ghanta R. K. (2019). How to bridge? Management of anticoagulation in patients with mechanical heart valves undergoing noncardiac surgical procedures. The Journal of Thoracic and Cardiovascular Surgery, 158, 200–203. https://doi.org/S0022-5223(18)31859-2.
doi: S0022-5223(18)31859-2
Won K. B., Lee S. H., Chang H. J., Shim C. Y., Hong G. R., Ha J. W., Chung N. (2014). Safety and cost-effectiveness of bridge therapies for invasive dental procedures in patients with mechanical heart valves. Yonsei Medical Journal, 55, 937–943. https://doi.org/10.3349/ymj.2014.55.4.937.
doi: 10.3349/ymj.2014.55.4.937