Anticoagulation Strategies In Patients On Long-term Anticoagulation Therapy In The Perioperative Period Of Non-cardiac Surgery:a Meta-analysis

Objective:To compare the effects of two different anticoagulant regimens(heparin bridging and non-bridging regimens interrupted or continued oral anticoagulants)on perioperative complications of non-cardiac surgery in patients treated with long-term oral anticoagulants.Methods:Systematically searched Pubmed,Web of Science,Medline,China Biomedical Literature Database(CBM),The Cochrane Library,Embase,China Journal Full-text Database(CNKI),Wanfang Resources and other databases,and consulted relevant review references.In addition,studies on perioperative anticoagulation regimens for patients receiving long-term anticoagulation therapy in non-cardiac surgery published from January 2009 to July 2022 were collected.Eligible articles were screened out according to the inclusion and exclusion criteria,and NOS score scale and Cochrane quality evaluation scale were used to evaluate the quality of the included literatures.Then,statistical software Revman 5.4 was used to obtain data from eligible studies and perform meta-analysis,Primary endpoints included major bleeding and thromboembolism.Secondary endpoints included minor bleeding,mortality,and total bleeding(major and minor bleeding).We performed a comparative analysis of bridging versus non-bridging,and a sensitivity analysis of patients undergoing major and minor surgery.Results eleven literatures with a total of 5751 subjects were included in the study.Results:A total of 11 eligible literatures were finally included,including 3 randomized controlled studies and 8 cohort studies.The total sample size was 5751 cases,including 3264 cases in the heparin bridging group and 2487 cases in the non-bridging(interrupted or continuous oral anticoagulant)group.Overall results showed that the perioperative heparin bridging protocol increased the risk of perioperative major bleeding(OR=2.37,95%CI:1.23～4.59,P=0.01),minor bleeding(OR=1.82,95%CI:1.50～2.21,P<0.00001),and total bleeding(OR=1.97,95%CI:1.36～2.86,P=0.0004)in patients with long-term oral anticoagulants at the onset of bleeding complications,compared with perioperative non-bridging protocol.There was no significant difference in the incidence of embolic complications between the heparin-bridging group and the non-bridging group(OR=0.68,95%CI:0.37～1.27,P=0.23).There was no significant difference in mortality risk between the heparin-bridged and non-bridged groups(OR=0.74,95%CI:0.38-1.44,P=0.37).Conclusion:Our analysis showed that perioperative bridging therapy significantly increased the risk of major bleeding,minor bleeding,and total bleeding in patients receiving non-cardiac surgery for long-term anticoagulant therapy compared with non-bridging therapy,while no significant differences were observed in the risk of embolism and death between the two groups.Given the limitations of this study,more high-quality randomized controlled clinical trials are needed to confirm the conclusions.