Original Research

Enoxaparin vs Continuous Heparin for Periprocedural Bridging in Patients With Atrial Fibrillation and Advanced Chronic Kidney Disease

Fed Pract. 2019 July;36(7):306-315

References

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Results

In total, 50 patients were analyzed in the study. There were 36 patients bridged with IV UFH at a concentration of 25,000 U/250 mL with an initial infusion rate of 12 U/kg/h. For the other arm, 14 patients were anticoagulated with renally dosed enoxaparin 1 mg/kg/d with an average daily dose of 89.3 mg; the mean actual body weight in this group was 90.9 mg (correlates with enoxaparin daily dose). Physicians of the primary team decided which parenteral anticoagulant to use. The difference in mean duration of inpatient parental anticoagulation between both groups was not statistically significant: enoxaparin at 7.1 days and UFH at 9.6 days (P = .19). Patients in the enoxaparin arm were off warfarin therapy for an average of 6.0 days vs 7.5 days for the UFH group (P = .29). The duration of outpatient anticoagulation with enoxaparin was not analyzed in this study.

Patient and Procedure Characteristics

All patients had AF or atrial flutter with 86% of patients (n = 43) having a CHADS₂ > 2 and 48% (n = 29) having a CHA₂DS₂VASc > 4. Overall, the mean age was 71.3 years with similarities in ethnicity distribution. Patients had multiple comorbidities as shown by a mean Charlson Comorbidity Index (CCI) of 7.7 and an increased risk of bleeding as evidenced by 98% (n = 48) of patients having a HAS-BLED score of ≥ 3. A greater percentage of patients bridged with enoxaparin had DM, history of stroke and MI, and a heart valve, whereas UFH patients were more likely to be in stage 5 CKD (eGFR < 15 mL/min/1.73m²) with a significantly lower mean eGFR (16.76 vs 22.64, P = .03). Furthermore, there were more patients on hemodialysis in the UFH (50%) arm vs enoxaparin (21%) arm and a lower mean CrCl with UFH (20.1 mL/min) compared with enoxaparin (24.9 mL/min); however, the differences in hemodialysis and mean CrCl were not statistically significant. There were no patients on peritoneal dialysis in this review.

Procedure Characteristics

The average Revised Cardiac Risk Index (RCRI) score was about 3, indicating that these patients were at a Class IV risk (11%) of having a perioperative cardiac event (Table 3). Nineteen patients (38%) elected for a major surgery with all but 1 of the surgeries (major or minor) being invasive. The average length of surgery was 1.2 hours, and patients were more likely to undergo cardiothoracic procedures (38%). There were 2 out of 14 (14%) patients on enoxaparin who were able to have surgery as an outpatient; whereas this did not occur in patients on UFH. The procedures completed for these patients were a colostomy (minor surgery) and arteriovenous graft repair (major surgery). There were no statistically significant differences regarding types of procedures between the 2 arms.

Outcomes

The primary outcome of this study, hospital LOS, differed significantly in the enoxaparin arm vs UFH: 10.2 days vs 17.5 days, P = .04 (Table 4). The time-to-discharge from initiation of parenteral anticoagulation was significantly reduced with enoxaparin (7.1 days) compared with UFH (11.9 days); P = .04. Although also reduced in the enoxaparin arm, ICU LOS did not show statistical significance (1.1 days vs 4.0 days, P = .09).

About 36% (n = 18) of patients in this study acquired an infection during hospitalization for elective surgery. The most common microorganism and site of infection were Enterococcus species and urinary tract, respectively (Table 5). Nearly half (44%, n = 16) of the patients in the UFH group had a nosocomial infection vs 14% (n = 2) of enoxaparin-bridged patients with a difference approaching significance; P = .056. Both patients in the enoxaparin group had the urinary tract as the primary source of infection; 1 of these patients had a urologic procedure.

Major bleeding occurred in 7% (n = 1) of enoxaparin patients vs 22% (n = 8) in the UFH arm, but this was not found to be statistically significant (P = .41). Minor bleeding was similar between enoxaparin and UFH arms (14% vs 19%, P = .99). Regarding thromboembolic complications, the enoxaparin group (0%) had a numerical reduction compared to UFH (11%) with VTE (n = 4) being the only occurrence of the composite outcome (P = .57). There were 4 deaths within 30 days posthospitalization—all were from the UFH group (P = .57). Due to the small sample size of this study, these outcomes (bleeding and thrombotic events) were not powered to detect a statistically significant difference.