Low-molecular weight heparin bridging therapy safe in elderly undergoing surgery following percutaneous coronary intervention

Impact of perioperative low-molecular-weight heparin therapy on clinical events of elderly patients with prior coronary stents implanted > 12 months undergoing non-cardiac surgery: a randomized, placebo-controlled trial

1. A randomized control trial found low-molecular weight heparin (LMWH) bridging therapy did not increase the frequency of perioperative acute myocardial infarction (MI), cardiac death, stroke, or major bleeding in elderly individuals that underwent surgery > 12 months after percutaneous coronary intervention (PCI) compared to the non-bridging group.  

Evidence Rating Level: 1 (Excellent) 

Many patients with coronary stents on antiplatelet drugs do not need invasive treatments, and it is key to examine their perioperative management. To understand the efficacy and safety of low molecular weight heparin (LMWH) bridging therapy for antiplatelet drug discontinuation, a randomized controlled trial recruited 2490 patients (of which 14 did not participate) from the Chinese PLA General Hospital. The patients were randomized in a 1:1 ratio to either receive LMWH bridging therapy with dalteparin sodium (2500 IU administered subcutaneously twice daily) or no bridging therapy (a matching subcutaneous placebo). The LMWH was paused during the surgery period, with the last dose given 24 hours before surgery and resuming LMWH 24 hours after surgery for those with low-to-moderate bleeding risk, and 48-72 hours later for those with a high bleeding risk. The LMWH bridging therapy group was assigned 1242 patients, while the placebo group was assigned 1234 patients. Aspirin was used to treat 1975 (79.77%) of patients, while clopidogrel was used to treat 386 (15.59%) patients. A significantly higher proportion of patients in the placebo (non-bridging) group were treated for two-vessel disease (46.76% vs. 41.94%, p = 0.016), while a lower proportion of patients were treated for a single-vessel disease (39.14% vs. 45.00%, p = 0.003). No significant difference was observed between the type of stent used in the two groups (p = 0.471). The experimental group had a lower rate of the combined endpoint when compared to the placebo group (5.79% vs. 8.42%, p = 0.012) and a lower rate of MI incidence (3.14% vs. 5.19%, p = 0.011) during the thirty-day follow-up period. The non-bridging group had a higher frequency of deep vein thrombosis compared to the bridging group (1.21% vs. 0.4%, p = 0.024) and a trend showed that there were more pulmonary embolisms in the non-bridging group comparatively (0.32% vs. 0.08%, p = 0.177). Independent predictors of ischemic events included LMWH bridging, creatinine clearance <30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus. While independent predictors of minor bleeding events included LMWH bridging, and a preoperative platelet count of < 70 x 109 /L. Overall, perioperative LMWH bridging was safe and efficacious for elderly patients who received coronary stents > 12 months prior undergoing non-cardiac surgery. 

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