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Pausing of anticoagulants in atrial fibrillation is dangerous and often unnecessary

Dr. Jochen Schuler, Dr. Günter Heyer

Oral anticoagulation ( OAC ) in patients with atrial fibrillation and high Thrombembolierisiko ( CHADS2 score> 1) represents one of the most effective prophylactic measures in internal medicine is (1). Accordingly, it is very common today , particularly in elderly patients. In our own surveys from 2007 in hospitalized medical patients from Salzburg were found in 22.3 % of patients over 75 years of oral vitamin K antagonists ( Sintrom ® , marcoumar ®) in the long-term medication (2).
The most common indication for the administration of OAK is atrial fibrillation nowadays. The group of people who are anticoagulated for atrial fibrillation will continue to grow in the future and the range of anticoagulants has teamed up with the new oral anticoagulants ( dabigatran ( Pradaxa ®) , rivaroxaban ( Xarelto ®) , apixaban ( Eliquis ®) ) last significantly expands , which facilitates the management of these patients only apparent.

A problem in the clinical management of orally anticoagulated patients always occurs when these need surgery and the OAC will be paused at the request of the operators or as thoughtless automaticity . Blood clotting then gets often confused the longer term and it is a rebound coagulation is concerned with increased thromboembolism after pausing .

With the new anticoagulants are made in this regard a few experiences . In the vitamin K antagonists , the Thrombembolierisiko can now be estimated quite well after the pause . According to a recent pharmacoepidemiological study from Denmark with nearly 50000 anticoagulated patients with atrial fibrillation (61% men, mean age 71 years ) is interrupted at least once within 3.5 years after initiation of therapy with three-quarters of the patients or discontinued entirely resist the OAC . Total in this register are registered on the OAK 67000 interruptions (3).

After settling or pause OAK to thromboembolism and deaths accumulated . The incidence of fatal and non-fatal thromboembolism during an interruption period was more than twice as high as under current OAK ( 14.2 vs . 6.9 events per 100 patient-years) . Unfortunately, it is not known from the register , why the OAC was interrupted in the individual case and whether work was bridging with heparin .

A pause OAK before dental procedures, gastroscopy or minor surgical procedures is therefore in terms of thromboembolic events not without danger , should be very carefully considered in individual cases or avoided where possible. Many of these surgeries can be performed safely in experienced hands under running OAK . In cardiology, for example found in recent years, more and more surgeons to over perform cardiac catheterization with continuous OAK and implanting pacemakers. A meta-analysis of published studies ( 4) has recently shown that a pacemaker implantation under constant OAK is even associated with significantly fewer bleeding complications than the long experienced perioperative " Heparinbridging " (OR 0.3 , 95 % CI: 0.18 - 0.5 , p < 0.01).
This is still very often found bridging the OAK - break with low molecular weight heparins ( LMWH) is not backed by randomized trials in other respects. The recommendations in this regard have the level of expert recommendations ( Level C). The periprocedural administration of LMWH compared to without replacement OAK - break does not seem to reduce the Thrombembolierate . This has recently publicized a " systematic review " of 34 published studies on this topic found (5). The heparin bridging had for this review only one effect : it tripled the incidence of perioperative bleeding complications !
Against this background, it is also of the European Society of Cardiology ( ESC) in the current guidelines on atrial fibrillation the " Heparinbridging " only at very high risk of stroke ( St.p. stroke, mechanical heart valve ) recommended (1) . To approach the Heparinbridging be made to the work of the Working perioperative coagulation of the Austrian Society of Anaesthesiology ( ÖGARI ) referenced (6).

Practically suggests the ESC right to carry out in patients with atrial fibrillation surgery with manageable risk of bleeding by continuing with the OAK in subtherapeutic range and - OAK continue in the evening or morning with the usual maintenance dose ( without re- loading) after the procedure - with adequate postoperative bleeding control . This approach would be closely coordinated with the surgeon and / or anesthetist. Generally, a little bleeding surgical method would be preferable , and of course to pay attention to a careful hemostasis.

In a cardiac catheterization and intervention anticoagulated patients with atrial fibrillation need the OAC rule no longer interrupt . The procedure can be performed in experienced hands very sure about the transradial access in these patients. This access path after bleeding is controlled very well even at full anticoagulation.

1 Camm AJ et al. 2010 ESC Guidelines for the management of atrial fibrillation Eur Heart J 2010 , 31, 2369
2 Schuler et al J . Wi climate where in 2008 , 120, 733
3 Raunsø J , et al. EUR Heart J 2012 , 33, 1886
4 Ghanbari H, et al. Am J Cardiol 2012 , 110, 1482
5 Siegal D et al. Circulation 2012 , 126 , 1630

Address for correspondence :
Dr. Jochen Schuler
Cardiac catheterization laboratory, Dr. Heyer
Lasserstraße 37 , 5020 Salzburg

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