Análisis de la seguridad y eficacia en el manejo de los procedimientos invasivos en una cohorte de pacientes bajo terapia anticoagulante oral con antagonistas de la vitamina K

Resumo

Introduction: Prevalence of patients with anticoagulant therapy has increased significantly in recent years, affecting approximately 1.5% of the population, mostly for stroke prevention associated with atrial fibrillation. Given the chronicity of this therapy, it is possible that at some point the patient must undergo an invasive procedure. In patients taking vitamin K antagonists (VKAs), the commonly accepted procedure for intervention requiring an invasive procedure is the temporary replacement of VKAs with low-molecular-weight heparin (LMWH), which is called bridging therapy. However, this practice lacks sufficient scientific evidence and the latest meta-analyses, reviews and consensus documents suggest that this practice may not lead to higher clinical benefit. Objectives: review the invasive procedures, the treatment applied and the periprocedural adverse events in a cohort of anticoagulated patients with VKA due to various indications. Material and methods: The clinical history of 559 patients from our cohort of patients under treatment with VKA was reviewed and invasive procedures were collected from April 1, 2017 to September 30, 2019. Thrombotic and hemorrhagic risks have been stratified according to risk scores from routine clinical practice, as well as the hemorrhagic risk of the procedure. Adverse events related to the procedure (up to 30 days post-procedure) have been collected: stroke or systemic embolism, major bleeding, clinically relevant non-major bleeding, and minor bleeding (according to ISTH criteria). Results. A total of 716 invasive procedures were analyzed in 559 patients. Of these, 443 (62%) received bridging therapy, mostly with LMWH at prophylactic doses (333 procedures, 46%). Of those who did not receive bridging therapy (273 procedures, 38%), in 201 interventions they discontinued VKA without receiving LMWH. In a total of 104 (14.5%) invasive procedures, the patients were under concomitant antiplatelet treatment, of which the majority seemed to have continued this treatment during the intervention. There was one arterial thrombosis and 36 bleeding events (incidence 5%). Of these, 14 were major and/or non-major clinically rellevant bleeding, all of these in bridging therapy patients, and 22 were minor bleeds. Carriers of valve prostheses (HR 2.86 [95% CI 1.40-5.84]; p=0.004), concomitant use of antiplatelets (HR 2.16 [95% CI 1.06-4.40]; p=0.033) and the use of LMWH as bridging therapy (HR 2.67 [95% CI 1.10-6.47]; p=0.029) were shown to be independently associated with the risk of periprocedural bleeding events. After adjusting for the type of invasive procedure, only major surgery (HR 3.62 [95% CI 1.34-9.76]; p=0.011) and bridging therapy with LMWH proved to be predictors of periprocedural bleeding events (HR 3.32 [95% CI 1.21-9.13]; p=0.020). Conclusions. The use of bridging therapy with heparin was independently associated with a significantly higher risk of periprocedural bleeding. As suggested by the latest clinical practice guidelines, a better stratification of patients is warranted, and bridging therapy is not indicated in all of them