Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

By J. Douketis, A. Spyropoulos, S. Kaatz, Richard C. Becker, J. Caprini, A. Dunn, D. Garcia, A. Jacobson, A. Jaffer, D. Kong and 4 more. New England Journal of Medicine, 2015

952 citations recorded by the source corpus.

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.)

Subfields: Cardiology and Cardiovascular Medicine, Internal Medicine

View Paper: https://www.semanticscholar.org/paper/c453c648f67ddf64d472fc7f79be1467127cc4fd

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In Cardiology and Cardiovascular Medicine

In Internal Medicine

Citations in the corpus

Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition) (2018, background): “A randomized, double-blind, placebo-controlled trial that compared dalteparin with placebo showed that there was no difference in the incidence of arterial thromboembolism between the 2 groups.(200) In addition, the incidence of major bleeding was 1.”
Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report (2012, methodology): “The role of bridging has been tested in a randomized trial, Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery (BRIDGE), performed in patients on warfarin who were candidates for an invasive procedure (patients wi”
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (2017, background): “In patient groups other than those with mechanical heart valves, increasing concerns have surfaced that bridging therapy exposes patients to higher bleeding risks without reducing the risk of thromboembolism (199).”
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (2017, background): “In patient groups other than those with mechanical heart valves, increasing concerns have surfaced that bridging therapy exposes patients to higher bleeding risks without reducing the risk of thromboembolism (199).”
2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. (2016, neutral): “2%, respectively).(502) OAC interruptions should be minimized to prevent stroke.”