Heparin bridging in peri-procedural management of new oral anticoagulant: a bridge too far?
Bibliographic record
Abstract
This editorial refers to ‘Peri-interventional management of novel oral anticoagulants in daily care: results from the prospective Dresden NOAC registry’‡, by J. Beyer-Westendorf et al., on page 1888. The new oral anticoagulants (NOACs) are attractive alternatives to vitamin K antagonists (VKAs) for patients requiring long-term anticoagulation. NOACs are at least as effective and safe as warfarin while allowing convenient fixed dosing regimens.1,2 Moreover, due to their rapid onset and offset of action,3 NOACs have the potential to simplify the peri-procedural management of patients requiring interruption of anticoagulant treatment for elective interventions. Beyer-Westendorf and colleagues now report thrombotic and bleeding outcomes during the first 30 days after an elective procedure from a prospective registry of 2179 patients receiving long-term NOAC therapy for atrial fibrillation (81%), venous thrombo-embolism (17%), or other indications (2%).4 During an 18-month period, 595 patients underwent a total of 863 elective procedures. Most patients were taking rivaroxaban (76%) or dabigatran (23.5%), and only a minority (0.5%) was taking apixaban. Patients who underwent procedures without interruption of NOAC therapy did not experience major bleeding and had a non-major clinically relevant bleed rate of < 5%. Patients who underwent a procedure with interruption of NOAC therapy and who received bridging anticoagulation [40% of patients; most commonly with low molecular weight heparin (LMWH)] had similar rates of thrombotic events compared with those who did not receive bridging (1.6% vs. 0.8%, P = 0.265), but experienced a five-fold increase in major bleeding (2.7% vs. 0.5%, P = 0.01). Rates of non-major clinically relevant and minor bleeding were similar in the two treatment groups irrespective of the use of bridging. Multivariate analysis revealed that the type of procedure (major vs. non-major) was an independent predictor for both thrombotic events [odds ratio (OR) 7.3; 95% confidence interval (CI) 1.9–28.5] and major bleeding (OR 16.8; 95% CI 3.8–78.9). Bridging predicted major bleeding (OR 5.9; 95% CI 1.2–20.4) but did not appear to protect patients against thrombotic events.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.003 | 0.013 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.003 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.001 | 0.002 |
| Scholarly communication | 0.005 | 0.005 |
| Open science | 0.003 | 0.001 |
| Research integrity | 0.008 | 0.012 |
| Insufficient payload (model declined to judge) | 0.010 | 0.005 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".