Bridging

Because of the recent publication of several important studies, there has been a major change in how we think about perioperative management of anticoagulation. Because of these changes, existing consensus guidelines are suddenly out of date and can no longer be used as is, particularly the 2012 American College of Chest Physicians Antithrombotic Guidelines, version 9. We estimate that well over 90% of patients receiving warfarin therapy should not receive bridging anticoagulation during periprocedural interruptions of therapy, except under unusual circumstances and with appropriate justification...

Chronic oral anticoagulation frequently requires interruption for various reasons and durations. Whether or not to bridge with heparin or other anticoagulants is a common clinical dilemma. The evidence to inform decision making is limited, making current guidelines equivocal and imprecise. Moreover, indications for anticoagulation interruption may be unclear. New observational studies and a recent large randomized trial have noted significant perioperative or periprocedural bleeding rates without reduction in thromboembolism when bridging is employed...

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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...

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In this executive summary of a Consensus Document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in atrial fibrillation (AF) patients. The main aim of the document was to summarise 'best practice' in dealing with bleeding risk in AF patients when approaching antithrombotic therapy, by addressing the epidemiology and size of the problem, and review established bleeding risk factors...

OBJECTIVE: The objectives of this study were to describe inpatient anticoagulation and bridging in patients with non-valvular atrial fibrillation (NVAF) and to identify whether differences exist in length of stay (LOS) among bridged versus non-bridged NVAF patients. DESIGN: Administrative claims data were used to select patients ≥18 years with a primary or secondary discharge diagnosis of NVAF and inpatient warfarin use from 1 July 2004 to 30 September 2009. Patients with valvular or transient causes of NVAF or pregnancy were excluded...

The perioperative management of patients with atrial fibrillation who require an elective surgical or other invasive procedure is an area of ongoing uncertainty. Accumulating evidence from observational studies suggests that the use of bridging anticoagulation with heparin, although well-intentioned, might not reduce perioperative thromboembolism and can increase bleeding.

In patients with atrial fibrillation (AF) who require interruption of dabigatran or warfarin for an elective surgery/procedure, the risks and benefits of perioperative bridging anticoagulation is uncertain.We accessed the database from RE-LY, a randomised trial comparing dabigatran with warfarin for stroke prevention in AF, to assess the potential benefits and risks of bridging. In patients who had a first interruption of dabigatran or warfarin for an elective surgery/procedure, we compared the risk for major bleeding (MB), stroke or systemic embolism (SSE) and any thromboembolism (TE) in patients who were bridged or not bridged during the period of seven days before until 30 days after surgery/procedure...

BACKGROUND: The efficacy of heparin-bridging therapy during the initiation of oral anticoagulation therapy (OAC) in non-valvular atrial fibrillation (NVAF) is unclear. OBJECTIVES: To evaluate the efficacy and the safety of heparin-bridging therapy during OAC initiation in NVAF patients. PATIENTS/METHODS: This study included 5327 consecutive warfarin-naïve NVAF patients who received OAC that was initiated with (n = 1053) or without (n = 4274) heparin bridging at four tertiary hospitals...

BACKGROUND: Temporary interruption of oral anticoagulation for procedures is often required, and some propose using bridging anticoagulation. However, the use and outcomes of bridging during oral anticoagulation interruptions in clinical practice are unknown. METHODS AND RESULTS: The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry is a prospective, observational registry study of US outpatients with atrial fibrillation...

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BACKGROUND: Antiplatelet agents given to prevent thromboembolic disease are frequently withdrawn prior to surgical procedures to reduce bleeding complications. This action may expose patients to increased thromboembolic morbidity and mortality. METHODS: A series of 2012 patients who had undergone gastroenterologic surgery between January 2005 and June 2010 at our institution were reviewed. Among this cohort, antiplatelet therapy (APT) was used in 519 patients (25...

BACKGROUND: Perioperative management with reduced-dose warfarin is of potential interest by eliminating the need for bridging while still maintaining a degree of anticoagulation. The outcomes of this regimen have not been well determined. METHODS: In a randomized controlled trial we compared two regimens for management of anticoagulation with warfarin in patients with implantation of a pacemaker or defibrillator. Half dose of warfarin for 3-6 days, depending on the baseline international normalized ratio (INR), before surgery aiming at an INR of ≤ 1...

Perioperative management of patients on chronic anticoagulant use involves balancing individual risk for thromboembolism and bleeding. Discontinuation of antithrombotic therapy can place patients at increased risk of thromboembolic complications, whereas continuing antithrombotic therapy can increase procedure-related bleeding risk. Temporary perioperative substitution of low-molecular weight heparin or unfractionated heparin in place of warfarin, "the bridge therapy" is often used in the periprocedural period, but the indications and timing of this is still uncertain...

Patients with mechanical heart valves (MHVs) are at a higher risk for thromboembolic events than patients with atrial fibrillation (AF). This difference is observed in the higher maintenance international normalized ratio (INR) range for patients with MHV and in the selection for anticoagulation bridge therapy when warfarin is interrupted perioperatively. However, once the decision is made to "bridge," the same therapeutic options, unfractionated heparin and subcutaneous low-molecular-weight heparin (LMWH), are applicable to the 2 patient populations...