Striking a Balance Between the Risks and Benefits of Anticoagulation Bridge Therapy in Patients with Atrial Fibrillation: Clinical Updates and Remaining Controversies

Abstract

Long-term anticoagulation with a vitamin K antagonist (VKA) or the new agent dabigatran is recommended to decrease stroke risk in patients with atrial fibrillation. When patients with atrial fibrillation undergo initiation or interruption of VKA therapy, or experience an isolated subtherapeutic international normalized ratio (INR), bridge therapy with a parenteral anticoagulant may be considered. To describe the literature for anticoagulation bridge therapy in patients with atrial fibrillation, we conducted a MEDLINE search (1966-February 2011) of the English-language literature to identify related studies. Ongoing clinical trials were identified through a search of the ClinicalTrials.gov registry. Major national and international guidelines were gathered and evaluated. Additional literature was obtained through review of relevant references of the identified articles. Bridging is not supported by guidelines or clinical trials for patients starting VKA therapy for atrial fibrillation. A subtherapeutic INR value during long-term VKA therapy may be associated with increased thromboembolic events, but the benefit of bridging has not been demonstrated. When VKA therapy is interrupted for procedures, retrospective and cohort data suggest that the decision to bridge should be based on a patient's thromboembolic and bleeding risks associated with the procedure. Typically, it is recommended to use bridge therapy in patients with atrial fibrillation at high risk for thromboembolism, but the benefit of bridging is less clear in patients at low risk. Not all procedures necessitate anticoagulation interruption. Recent trials suggest that VKAs can be continued when patients are undergoing cardiac device procedures and some types of radiofrequency ablation. Several clinical trials are ongoing that will provide more definitive guidance for perioperative anticoagulation management of patients with atrial fibrillation. Patients taking dabigatran are unlikely to require bridge therapy because of a predictable anticoagulant effect and rapid onset of action. However, evidence for optimal perioperative management of dabigatran is needed.

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

“…First, recommendations in guidelines9, 10, 12 and summaries of product characteristics14, 15 do not strongly advise against bridging therapy. Indeed, several health professionals have criticized the lack of clarity of these guidelines 17, 18, 19, 42, 43…”

Patients with Atrial Fibrillation Undergoing Total Joint Arthroplasty Increase Hospital Burden

“…Although many consider total joint arthroplasty to be a procedure that is associated with a high risk of thrombotic and bleeding events, Chana et al and Rhodes et al suggested that interruption of warfarin therapy is not required during joint arthroplasty and does not lead to a higher rate of complications 22,23 . As these were both small retrospective studies with few patients (twenty-four and thirty-eight patients, respectively), we suggest that larger clinical trials in patients undergoing total joint arthroplasty will provide more definitive guidance for perioperative anticoagulation management of patients who have atrial fibrillation 24 .…”

Anti-Coagulation and Deep Brain Stimulation: Never the Twain Shall Meet?

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