Bridging bei antikoagulierten Patienten – neue Empfehlungen

 

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Zusammenfassung

Periprozedurales Gerinnungsmanagement bei Patienten, die unter einer Langzeitantikoagulation stehen und sich einem Eingriff unterziehen müssen, ist häufig eine Herausforderung. Unter dem Konzept des „Bridgings“ versteht man die Überbrückung der Unterbrechung der Therapie mit einem Vitamin-K-Antagonisten durch ein niedermolekulares Heparin. Mehrere Studien haben in den letzten Jahren das Konzept des Bridgings kritisch hinterfragt. Aktuell liegen Ergebnisse aus dem ORBIT-AF-Register und der prospektiv-randomisierten BRIDGE-Studie vor. Die häufigsten Komplikationen eines Bridgings sind Blutungen. Insgesamt hat das Konzept des Bridgings durch die neuen Studien an Attraktivität verloren, insbesondere was Eingriffe mit geringem oder mittlerem Risiko und Patienten ohne hohes thromboembolisches Risiko betrifft. Es wird empfohlen, für jeden Patienten individuell über das periprozeduale Vorgehen zu entscheiden und Patienten- und eingriffsbedingte Faktoren gegeneinander abzuwägen. Dies gilt für VKA wie für NOAKs. Dabei sind das individuelle thromboembolische Risiko, das spezifische Blutungsrisiko des Eingriffs und patientenspezifische Faktoren (z. B. Niereninsuffizienz) die entscheidenden Faktoren.

Abstract

Peri-interventional management of anticoagulation in patients receiving long-term anticoagulation can be challenging. The concept of „bridging“ is known as an application of an anticoagulant with a short half-life (e. g. low-molecular-heparin) during interruption of therapy with vitamin-k-antagonists. Multiple studies have critically investigated the concept of bridging. Recently data from the ORBIT-AF-Register and the prospective randomized BRDIGE-Study have been released. The most common complication of bridging is bleeding. Overall the concept of bridging has lost some of its attractivity, especially concerning low or intermediate risk interventions or patients with a low risk of thromboembolism. An individual peri-interventional management based on individual patients’ risk profile and interventional factors is recommended for VKA and NOACs. Main points of consideration are individual thromboembolic risk, specific bleeding risk of the planned intervention as well as patient factors (e. g. renal insufficiency).

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