Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

Abstract

BACKGROUND It is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding. METHODS We performed a randomized, double-blind, placebo-controlled trial in which, after perioperative interruption of warfarin therapy, patients were randomly assigned to receive bridging anticoagulation therapy with low-molecular-weight heparin (100 IU of dalteparin per kilogram of body weight) or matching placebo administered subcutaneously twice daily, from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. Warfarin treatment was stopped 5 days before the procedure and was resumed within 24 hours after the procedure. Follow-up of patients continued for 30 days after the procedure. The primary outcomes were arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding. RESULTS In total, 1884 patients were enrolled, with 950 assigned to receive no bridging therapy and 934 assigned to receive bridging therapy. The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (risk difference, 0.1 percentage points; 95% confidence interval [CI], −0.6 to 0.8; P = 0.01 for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P = 0.005 for superiority). CONCLUSIONS In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health; BRIDGE ClinicalTrials.gov number, NCT00786474.)

Perioperative interruption of direct oral anticoagulants in patients with atrial fibrillation: A systematic review and meta‐analysis

“…In a recent randomized controlled trial,28 the 30‐day postoperative thrombotic risks were 0.4% and 0.3% in the no‐bridging and bridging groups, respectively, which are similar to our pooled DOAC risk of 0.41%. Similarly, the risk of postoperative thromboembolism was 0.4% overall in a recently published prospective registry evaluating the perioperative interruption of VKA 29.…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…When interruption of OAC is required, bridging does not seem to be beneficial, except in patients with mechanical heart valves: In a randomized trial of 1884 patients with AF, interruption of anticoagulation was non-inferior to heparin bridging for the outcome of arterial thrombo-embolism (incidence of 0.4% and 0.3%, respectively) and resulted in a lower risk of major bleeding (1.3% and 3.2%, respectively). 502 OAC interruptions should be minimized to prevent stroke. 9.6 Management of bleeding events in anticoagulated patients with atrial fibrillation 9.6.1 Management of minor, moderate, and severe bleeding General assessment of an anticoagulated patient with AF experiencing a bleeding event should include the assessment of bleeding site, onset, and severity of the bleeding, the time-point of last intake of OAC and other antithrombotic drugs, and other factors influencing bleeding risk such as CKD, alcohol abuse, and concurrent medications.…”

Short‐Term Risk of Bleeding During Heparin Bridging at Initiation of Vitamin K Antagonist Therapy in More Than 90 000 Patients With Nonvalvular Atrial Fibrillation Managed in Outpatient Care

“…Recently, several studies have examined the risks of bleeding and of ischemic stroke and systemic embolism (IS/SE) associated with perioperative heparin bridging anticoagulation in patients with NVAF 3, 4, 5, 6. However, no studies have investigated bridging risks during VKA initiation in outpatient settings.…”