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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 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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“The study found that the no bridging strategy was inferior to the low molecular weight heparin bridging therapy for the prevention of thromboembolic events, while at the same time, it determined a reduction in the risk of major bleedings [48].”
Background
Metadata
- 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
- 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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