Yonsei Med J.  2014 Jul;55(4):937-943. 10.3349/ymj.2014.55.4.937.

Safety and Cost-Effectiveness of Bridge Therapies for Invasive Dental Procedures in Patients with Mechanical Heart Valves

Affiliations
  • 1Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan.
  • 2Department of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Korea. hjchang@yuhs.ac
  • 3Severance Biomedical Science Institute, Seoul, Korea.

Abstract

PURPOSE
Bridge anticoagulation therapy is mostly utilized in patients with mechanical heart valves (MHV) receiving warfarin therapy during invasive dental procedures because of the risk of excessive bleeding related to highly vascular supporting dental structures. Bridge therapy using low molecular weight heparin may be an attractive option for invasive dental procedures; however, its safety and cost-effectiveness compared with unfractionated heparin (UFH) is uncertain.
MATERIALS AND METHODS
This study investigated the safety and cost-effectiveness of enoxaparin in comparison to UFH for bridge therapy in 165 consecutive patients (57+/-11 years, 35% men) with MHV who underwent invasive dental procedures.
RESULTS
This study included 75 patients treated with UFH-based bridge therapy (45%) and 90 patients treated with enoxaparin-based bridge therapy (55%). The bleeding risk of dental procedures and the incidence of clinical adverse outcomes were not significantly different between the UFH group and the enoxaparin group. However, total medical costs were significantly lower in the enoxaparin group than in the UFH group (p<0.001). After multivariate adjustment, old age (> or =65 years) was significantly associated with an increased risk of total bleeding independent of bridging methods (odds ratio, 2.51; 95% confidence interval, 1.15-5.48; p=0.022). Enoxaparin-based bridge therapy (beta=-0.694, p<0.001) and major bleeding (beta=0.296, p=0.045) were significantly associated with the medical costs within 30 days after dental procedures.
CONCLUSION
Considering the benefit of enoxaparin in cost-effectiveness, enoxaparin may be more efficient than UFH for bridge therapy in patients with MHV who required invasive dental procedures.

Keyword

Anticoagulation; bridge therapy; dental procedure; low molecular weight heparin; mechanical heart valve

MeSH Terms

Aged
Anticoagulants/*therapeutic use
Dentistry, Operative/*methods
Enoxaparin/therapeutic use
Female
*Heart Valve Prosthesis
Heparin, Low-Molecular-Weight/*therapeutic use
Humans
Male
Middle Aged
Anticoagulants
Enoxaparin
Heparin, Low-Molecular-Weight

Reference

1. Cannegieter SC, Rosendaal FR, Briët E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation. 1994; 89:635–641.
Article
2. Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126:3 Suppl. 204S–233S.
3. Palareti G, Hirsh J, Legnani C, Manotti C, D'Angelo A, Pengo V, et al. Oral anticoagulation treatment in the elderly: a nested, prospective, case-control study. Arch Intern Med. 2000; 160:470–478.
4. Wahl MJ, Howell J. Altering anticoagulation therapy: a survey of physicians. J Am Dent Assoc. 1996; 127:625–626. 629–630. 633–634 passim.
Article
5. Lim W, Wang M, Crowther M, Douketis J. The management of anticoagulated patients requiring dental extraction: a cross-sectional survey of oral and maxillofacial surgeons and hematologists. J Thromb Haemost. 2007; 5:2157–2159.
Article
6. Ward BB, Smith MH. Dentoalveolar procedures for the anticoagulated patient: literature recommendations versus current practice. J Oral Maxillofac Surg. 2007; 65:1454–1460.
Article
7. Katholi RE, Nolan SP, McGuire LB. The management of anticoagulation during noncardiac operations in patients with prosthetic heart valves. A prospective study. Am Heart J. 1978; 96:163–165.
Article
8. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008; 52:e1–e142.
9. Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J. 2007; 28:230–268.
Article
10. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010; 138:1093–1100.
Article
11. Schulman S, Kearon C. Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost. 2005; 3:692–694.
Article
12. Nematullah A, Alabousi A, Blanas N, Douketis JD, Sutherland SE. Dental surgery for patients on anticoagulant therapy with warfarin: a systematic review and meta-analysis. J Can Dent Assoc. 2009; 75:41.
13. Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133:6 Suppl. 299S–339S.
14. Warkentin TE, Levine MN, Hirsh J, Horsewood P, Roberts RS, Gent M, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med. 1995; 332:1330–1335.
Article
15. Bickler P, Brandes J, Lee M, Bozic K, Chesbro B, Claassen J. Bleeding complications from femoral and sciatic nerve catheters in patients receiving low molecular weight heparin. Anesth Analg. 2006; 103:1036–1037.
Article
16. Hardy RG, Williams L, Dixon JM. Use of enoxaparin results in more haemorrhagic complications after breast surgery than unfractionated heparin. Br J Surg. 2008; 95:834–836.
Article
17. Bui HT, Krisnaswami A, Le CU, Chan J, Shenoy BN. Comparison of safety of subcutaneous enoxaparin as outpatient anticoagulation bridging therapy in patients with a mechanical heart valve versus patients with nonvalvular atrial fibrillation. Am J Cardiol. 2009; 104:1429–1433.
Article
18. Pettinger TK, Owens CT. Use of low-molecular-weight heparin during dental extractions in a medicaid population. J Manag Care Pharm. 2007; 13:53–58.
Article
19. Spyropoulos AC, Frost FJ, Hurley JS, Roberts M. Costs and clinical outcomes associated with low-molecular-weight heparin vs unfractionated heparin for perioperative bridging in patients receiving long-term oral anticoagulant therapy. Chest. 2004; 125:1642–1650.
Article
20. Ferreira I, Dos L, Tornos P, Nicolau I, Permanyer-Miralda G, Soler-Soler J. Experience with enoxaparin in patients with mechanical heart valves who must withhold acenocumarol. Heart. 2003; 89:527–530.
Article
21. Kovacs MJ, Kearon C, Rodger M, Anderson DR, Turpie AG, Bates SM, et al. Single-arm study of bridging therapy with low-molecular-weight heparin for patients at risk of arterial embolism who require temporary interruption of warfarin. Circulation. 2004; 110:1658–1663.
Article
22. Douketis JD, Johnson JA, Turpie AG. Low-molecular-weight heparin as bridging anticoagulation during interruption of warfarin: assessment of a standardized periprocedural anticoagulation regimen. Arch Intern Med. 2004; 164:1319–1326.
Article
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