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 in patients with atrial fibrillation (AF) who had warfarin treatment temporarily interrupted for an elective operation or procedure, according to a study of 1,884 patients. Of these patients, 950 were assigned to receive no bridging therapy and 934 received bridging therapy. Researchers found:

• Incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group.

• Incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group.

Citation: Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015; 373:823-833. doi: 10.1056/NEJMoa1501035.

Commentary: It is common for patients with atrial fibrillation to need interruption of their anticoagulation in order to have an elective invasive or surgical procedure. Since warfarin is typically stopped 5 days before the procedure and restarted soon afterward, with about a week needed for the INR to come up to therapeutic level, some physicians advocate bridging therapy with low-molecular weight heparin to minimize the amount of time a patient is not anticoagulated. This study shows no advantage in decreasing stroke risk, but an important increase in the risk of major bleeding with bridging therapy in average risk patients. The current American College of Chest Physicians’ recommendations are: In patients requiring vitamin K antagonist (VKA) interruption before surgery, stop VKAs 5 days before surgery. In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, bridging anticoagulation is recommended during VKA interruption. In patients at low risk, not using bridging is recommended.¹ — Neil Skolnik, MD

1. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141;e326S-e350S.