Bridging therapy in oral anticoagulated patients: focusing on how to do it.

parison, at data from an inception cohort, multicentre, Italian study published in 1996 in which about 35% of all the new patients starting anticoagulation and enrolled in the study were aged 70 years or more [1]. In 2006 the proportion of patients aged over 70 years among the almost 800 new patients referred to our outpatient anticoagulation clinic to start warfarin treatment for the first time was 50%, more than one third of them being older than 80 years. Clinicians are increasingly called on to manage anticoagulated patients during perioperative periods, a far from easy task. The job requires careful assessment of the thrombotic and bleeding risk expected in each patient depending on the type of invasive procedure prescribed and a decision on the proper perioperative treatment. Many aspects need to be considered: (a) the risk of arterial and venous thromboembolism depending on both personal and procedural characteristics if anticoagulation is discontinued, and (b) the risk of bleeding if anticoagulation is continued or some type of alternative intervention is prescribed. The efficacy and safety of alternative interventions also needs to be addressed. Unfortunately, in this difficult task clinicians cannot count on proper support from the literature, mainly because of the lack of prospective controlled trials and the high variety of patient populations, procedures and possible alternative anticoagulation regimens. In the absence of randomised trials, we must rely on the available evidence. Results from recent registry studies have helped determine the risk of thrombotic (mainly arterial) and bleeding complications in various groups of patients, during different procedures and with different anticoagulation regimens (for a review of available studies see ref. [2]). There is substantial agreement among Consensus groups [3, 4] on the need for adequate perioperative protection (“bridging anticoagulation”) against thrombotic complications in categories of patients at high-intermediate risk; indications for those at moderate/low risk however are more varied, and some differences exist as to which Intern Emerg Med (2007) 2:247–249 DOI 10.1007/s11739-007-0074-2