Bridging Anticoagulation in Atrial Fibrillation | Journal Scan

Study Questions:

Is perioperative bridging with low molecular weight heparin necessary in patients with atrial fibrillation undergoing elective surgical procedures?


BRIDGE (Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery) was a randomized, double-blind, placebo-controlled trial in which patients discontinuing warfarin were randomly assigned to receive 100 IU of dalteparin per kilogram of body weight or placebo administered subcutaneously twice daily from 3 days before the procedure until 24 hours before the procedure and then for 5-10 days after the procedure. Endpoints of arterial thromboembolism and major bleeding were assessed at the end of the follow-up up to 30 days after procedure.


A total of 950 patients were assigned to receive bridging and 934 patients to no bridging. The incidence of arterial thromboembolism was 0.4% in the no bridging and 0.3% in the bridging group (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 (p = 0.005 for superiority).


In patients with atrial fibrillation undergoing an elective surgery or other elective invasive procedure, there was no statistically significant difference in the rate of arterial thomboembolism between patients who did and did not receive bridging. There was a significant increase of major bleeding in the bridging group.


The findings of this randomized double-blind trial are consistent with prior nonrandomized studies. Discontinuation of warfarin did not lead to rebound hypercoagulability. Invasive procedures did not increase prothrombotic tendencies. Unfortunately, although the mean CHADS2 score was 2.3, there were very few patients with a CHADS2 score of 5 or 6; therefore, the findings of this paper should not be applied to those patients. Additionally, patients undergoing major surgeries with high rates of bleeding, such as carotid endarterectomy, cardiac surgery, neurosurgery, and major cancer surgery, were not included in the trial. The strategy of foregoing anticoagulation in the perioperative period for moderate-risk patients undergoing lower-risk surgeries or invasive procedures appears to be well supported in this study.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias

Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Anticoagulants, Body Weight, Cardiac Surgical Procedures, Dalteparin, Double-Blind Method, Surgical Procedures, Elective, Hemorrhage, Heparin, Low-Molecular-Weight, Incidence, Perioperative Period, Thromboembolism, Thrombophilia, Warfarin

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