Pappas et al.: Cost-Effectiveness of Bridging Anticoagulation
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J Gen Intern Med DOI: 10.1007/s11606-019-05321-y © Society of General Internal Medicine 2019
o the Editor, TI read this article with concern. To my knowledge, no interventional or observational study has ever demonstrated the effectiveness of bridging anticoagulation for any subset of patients, though many studies have examined the issue.1 To be more precise, no study has ever demonstrated a benefit in terms of preventing thromboembolism, though the theoretical possibility of such a benefit does exist. However, multiple studies have clearly demonstrated important harms in terms of bleeding events.1 It seems questionable, therefore, to use simulation to quantify a benefit that has never actually been demonstrated, even in subgroup analyses of the empirical studies that have been done. Furthermore, the authors have used the HAS-BLED and CHADS2 scores to stratify patients in terms of bleeding and clotting risks. These scores are designed to risk-stratify bleeding risk per year of anticoagulation,2 or thromboembolism risk across a lifetime of atrial fibrillation without anticoagulation.3 These scores are not designed or validated to risk-stratify thromboembolism risk for a 1-week interruption of therapy, or bleeding risk for a 1-week course of low molecular weight heparin, and may not be valid for this purpose. While some studies, such as the BRIDGE trial, have quite reasonably used such scores to guide study design,4 that does not constitute validation of their utility for this purpose. I am concerned that casual readers may infer from reading this article that bridging anticoagulation is a proven intervention that is recommended for a selected subset of patients. Rather, I would submit that the current evidence
Received May 9, 2019 Accepted August 22, 2019
suggests it should be avoided for nearly all patients, or at least given only to highly selected patients after appropriate disclosure that this is a risky intervention that, while theoretically reasonable, has never been proven to benefit any subset of patients, no matter how carefully selected.1
Adam J. Rose, MD MSc 1 1
Boston University School of Medicine, Boston, MA, USA Corresponding Author: Adam J. Rose, MD MSc; Boston University School of Medicine, Boston, MA, USA (e-mail: [email protected]).
Compliance with Ethical Standards: Conflict of Interest: The author declares that he does not have a conflict of interest.
REFERENCES 1. 2.
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Rose AJ, Allen AL, Minichello T. A call to reduce the use of bridging anticoagulation. Circ Cardiovasc Qual Outcomes. 2016;9:64–67. Pisters R, Lane DA, Nieuwlaat R, DeVos CB, Crijns HG, Lip GYH. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation. Chest. 2011;138:1093–1100. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864–2870. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging
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