To bride or not to bridge; that is the question! As the Baby Boomers continue to age, we find ourselves in the midst of an atrial fibrillation epidemic. Many of these patients, particularly those over 65 with risk factors require chronic oral anticoagulation. Additionally, we have multitudes of other patients on chronic anticoagulation for venous thromboembolism (VTE) or other medical conditions. For decades, we have used vitamin K antagonists such as warfarin. Due to complex monitoring and dosage adjustments, drug interactions and potential side effects such as hemorrhagic stroke and gastrointestinal bleeding, patients and providers have always hoped an alternative to warfarin would come along. Over the last few years, a multitude of target specific oral anticoagulants (TSOAC’s) for treatment of nonvalvular atrial fibrillation have been approved. TSOAC’s are not without their own drawbacks (bleeding, lack of a specific antidote for some) significant cost, but for many, they remain an advance over warfarin.

Previously on iMedicalApps, we reviewed a number of outstanding apps for assisting providers caring for patients on anticoagulation including Anticoag Evaluator , MAQI2 Anticoagulation Toolkit , DAPT app, and BridgeAnticoag. An alternative to the ACC’s BridgeAnticoag is called Managing Anticoagulation in the Periprocedural Period (MAPPP). The app was created by the Island Peer Review Organization (IPRO) in 2014 and updated in 2016. The IPRO group worked with a multi-disciplinary team in New York with funding by the Medicare Quality Improvement Organization for New York. The purpose of the app is to assist providers caring for patients on anticoagulation (vitamin K antagonists, TSOAC’s, and/or anti-platelets) who require surgery or other medical procedures. Unlike the ACC’s app, MAPPP does not just apply to patients with non-valvular atrial fibrillation, but any patient on anticoagulation for any reason. It helps providers answer the following questions. Should the anticoagulation be interrupted and if so when? When can it be restarted? Should the patient be bridged with heparin or low-molecular weight heparin anymore?

Clinical Scenario

A 70 year-old male with a past medical history of hypertension and nonvalvular atrial fibrillation on apixaban with normal renal function presents to clinic for a preoperative evaluation. The patient is undergoing a total prostatectomy for prostate cancer. When should his anticoagulation be interrupted? When should it be restarted? What if the patient was on warfarin? Does he need to be bridged? What if he had an artificial heart valve?

Video Review

Login to iMedicalApps in order to view the following video review of MAPP app. Registration for iMedicalApps is free.

Evidence based medicine

The MAPPP app takes current medical literature on periprocedural to create a helpful POC tool to assist providers in managing patients with on anticoagulation for virtually any reason, who require procedures/surgery. It provides evidence-based information to decide if/when to stop anticoagulation, when to restart and who to bridge, all at the point of care.

What providers would benefit from this App?

Students, residents, mid-levels, Family Medicine, Internal Medicine, Emergency Medicine, Cardiology, anticoagulation clinic personnel. Any provider who prescribes or manages patients on anticoagulation, performs procedures/surgeries, and/or preop clearance.

Disclaimer: The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.

  • Price
    • Free
    • Easy to use, faster than ACC app.
    • Evidence-based outcome data with clear recommendations on stop/start times.    
    • Available for Android
  • Dislikes
    • App doesn’t reference the 2016 ACC guidelines on this topic.
    • App doesn’t include NNT/NNH; just “yes/no” type answers and timing information.
    • No internet based resources or links to references.
  • Overall

    IPRO’s MAPPP app is an excellent alternative to the ACC’s BridgeAnticoag app. It is evidence-based with multiple recent references. However, it does not cite the recent 2016 ACC guideline on periprocedural management of anticoagulation. I was unable to generate conflicting recommendations between the two apps, but their approach to the various questions are somewhat different. Therefore, I am uncertain if one could potentially violate “standard of care” by not following the ACC app recommendations (although primarily “expert opinion” based). One advantage to MAPPP is that it is NOT just for patients with nonvalvular afib like BridgeAnticoag. For those other patients, MAPPP may be the best choice currently available. The app is available for both iOS and Android platforms.

  • Overall Score
  • User Interface

    Very easy to use and faster than the ACC app with fewer steps.

  • Multimedia Usage

    App has references, but no links to those references or much information about the company behind the app.

  • Price

    A great resource for free.

  • Real World Applicability

    An excellent alternative app to the ACC BridgeAnticoag app for anyone who treats patients on anticoagulation and either performs procedures and/or performs preoperative clearance. My primary reservation is the lack of inclusion of the most recent ACC guidelines in this app although I couldn’t generate difference results.

  • Device Used For Review

    iPhone 6S running iOS 10.3

  • Available for DownloadAndroidiPhoneiPad