Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation
Open accessAbstract
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.).
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In a randomized trial of 1884 patients with AF, interruption of anticoagulation was non-inferior to heparin administration for arterial thromboembolism (incidence 0.4% and 0.3%, respectively) and resulted in a lower risk of major bleeding (1.3% and 3.2%, respectively).
“In a randomized trial of 1884 patients with AF, interruption of anticoagulation was non-inferior to heparin administration for the outcome of arterial thromboembolism (incidence of 0.4% and 0.3%, respectively) and resulted in a lower risk of major bleeding (1.3% and 3.2%, respectively).502”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [502]
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“2%, respectively).(502) OAC interruptions should be minimized to prevent stroke.”
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“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).”
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“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).”
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“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 with mechanical valve…”
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2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery
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JCS/JSCS/JATS/JSVS 2020 Guidelines on the Management of Valvular Heart Disease
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications
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JCS 2020 Guideline Focused Update on Antithrombotic Therapy in Patients With Coronary Artery Disease
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“The Bridging Anticoagulation in Patients Who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery (BRIDGE) trial evaluated this strategy in AF patients receiving warfarin with at least one risk factor for stroke (but no recent stroke or TIA) undergoing non-cardiac surgical p…”
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2020 ACC/AHA guideline for the management of patients with valvular heart disease
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“There is now a randomized, double-blind, placebo-controlled trial of bridging in AF patients (Douketis et al , 2015).”
2020 Clinical guidelines for Atrial fibrillation and atrial flutter
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“The BRIDGE trial has shown that in VKA-treated patients, bridging with LMWH has no benefit regarding thromboembolism but is instead an inferior strategy, since it can lead to a higher incidence of major bleeding [224].”
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“A few weeks after the final panel voting meeting, the PERIOP-2 trial was published as full text showing similar results to the BRIDGE trial (72).”
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Social determinants of atrial fibrillation
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Guidance for the practical management of warfarin therapy in the treatment of venous thromboembolism
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“There are relatively few studies of the risks of haemorrhage for endoscopic procedures in patients who continue antithrombotic therapy, therefore much of the data underlying the risk levels for these procedures applies to the baseline risk of haemorrhage without antithrombotic therapy ( ▶ Table3 ).”
JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias
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“Data from cardiovascular studies showed that warfarin interruption in atrial fibrillation increases the risk of thromboembolic events, and bridging therapy does not prevent such events; in fact, low molecular-weight heparin (LMWH) increases the risk of major perioperative bleeding.[56,57] In a recent meta-analysis of…”
BackgroundAnesthetic management of geriatric patients
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“In the majority of cases, perioperative bridging anticoagulation is no longer recommended when using novel oral anticoagulants and vitamin-K antagonists [64].”
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“(11), RE-LY (Randomized Evaluation of Long Term Anticoagulant Therapy With Dabigatran Etexilate) (28), and BRIDGE (4).”
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EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer
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2024 EACTS Guidelines on perioperative medication in adult cardiac surgery
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Bleeding after endoscopic submucosal dissection: Risk factors and preventive methods
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Reimagining Anticoagulation Clinics in the Era of Direct Oral Anticoagulants
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“tion of thromboembolism and decreased the occurrence of major bleeding.(156)”
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Guideline of guidelines: thromboprophylaxis for urological surgery
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Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update
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Initial management for acute lower gastrointestinal bleeding
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Holmium Laser Enucleation of the Prostate in Patients Requiring Anticoagulation
Tayeb, M. M. E., Jacob, J. M., Bhojani, N., Bammerlin, E., & Lingeman, J. E. (2016) · Journal of Endourology · doi:10.1089/end.2016.0070 · Cited by 85 · see citing works
- Authors
- Douketis, J. D., Spyropoulos, A. C., Kaatz, S., Becker, R. C., Caprini, J. A., Dunn, A. S., Garcia, D. A., Jacobson, A., Jaffer, A. K., Kong, D. F., Schulman, S., Turpie, A. G. G., Hasselblad, V., & Ortel, T. L.
- Affiliations
- Rush University Medical Center (US)
- Northwell Health (US)
- Hurley Medical Center (US)
- University of Cincinnati (US)
- Endeavor Health (US)
- University of Washington Medical Center (US)
- Duke Medical Center (US)
- McMaster University (CA)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2015-08-27
- Volume
- 373
- Issue
- 9
- Pages
- 823-833
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC4931686
- OpenAlex
- W1837600385
- Cited by
- 1,184
- References
- 46
- Citations by year
- 2026: 63 · 2025: 64 · 2024: 79 · 2023: 70 · 2022: 87 · 2021: 115 · 2020: 132 · 2019: 117 · 2018: 134 · 2017: 141 · 2016: 141 · 2015: 35 · 2014: 3
- FWCI
- 109.42
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health
- National Heart, Lung, and Blood Institute (U01HL086755, U01HL087229)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
- Health Sciences › Medicine › Hematology › Blood Coagulation and Thrombosis Mechanisms
- Keywords
- atrial fibrillation, low molecular weight heparin, dalteparin, warfarin interruption, arterial thromboembolism, major bleeding, elective surgery, non-inferiority, stroke prevention, systemic embolism, transient ischemic attack, postoperative bleeding risk
- MeSH terms
- Adult, Anticoagulants, Atrial Fibrillation, Double-Blind Method, Female, Hemorrhage, Heparin, Low-Molecular-Weight, Humans, Male, Postoperative Complications, Thromboembolism, Warfarin, Elective Surgical Procedures, Perioperative Period
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