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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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BackgroundBridging unter Antikoagulation und Thrombozytenaggregationshemmung
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“Similar lack of benefit of a bridging approach in the perioperative context has been demonstrated in the BRIDGE trial.(5) This trial included 1884 patients with nonvalvular AF who required vitamin K antagonist cessation for surgery.”
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“Blutungsrisiko Die Einschätzung eines peri- und postoperativen Blutungsrisikos ist ausgesprochen schwierig, sodass zwar zahlreiche Hinweise, aber keine etablierten Empfehlungen bestehen [32–34].”
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Perioperative Stroke in a Patient Undergoing Noncardiac, Non-Neurosurgical Procedure: A Case Report
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“The rate of thromboembolism is low in both bridged and non-bridged patients [11,12]; the decision to initiate anticoagulation post-surgery is based on the type of surgery, adequate hemostasis, and individual risks factors.”
BackgroundThe role of heparin bridging in lung cancer surgery: a nationwide database analysis
Mori, M., Ibayashi, K., Kanayama, M., Takenaka, M., Kuroda, K., Muramatsu, K., Fujino, Y., Matsuda, S., & Tanaka, F. (2020) · Surgery Today · doi:10.1007/s00595-020-02165-6 · Cited by 1
“1 3 the prevention of arterial thromboembolism and it also decreased the risk of major bleeding [18].”
BackgroundMethodGérer les anticoagulants avant une chirurgie programmée
Godon, A. (2021) · Oxymag · doi:10.1016/j.oxy.2021.07.003 · Cited by 1
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Fujikawa, T. (2022) · Cureus · doi:10.7759/cureus.23471 · Cited by 1
“Moreover, the use of heparin is now well recognized as a significant risk factor for postoperative bleeding and should be avoided if feasible [7,15].”
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Dzhioeva, O. N., Александровна, Р. Е., & Drapkina, O. M. (2023) · Rational Pharmacotherapy in Cardiology · doi:10.20996/1819-6446-2022-12-12 · Cited by 1
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Perioperativer Umgang mit oralen Antikoagulanzien
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“34,46,47 Evidence-based guidelines would help surgeons manage the opposing risks of surgical delay and bleeding and would help reduce the high mortality rates after this injury.”
Anticoagulation in the Intensive Care Unit
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Preoperative and Postoperative Care of Patients with Neurologic Disorders
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Comentarios sobre: Perioperative bridging anticoagulation in patients with atrial fibrillation
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The new, direct, target-specific oral anticoagulants
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“The BRIDGE study was a large randomized trial that compared bridging with low-molecularweight heparin or placebo in patients anticoagulated with warfarin undergoing different types of surgeries [10].”
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“Moreover, Douketis et al reported that heparin replacement during a palliative surgery did not decrease thromboembolic events and increased the risk of major bleeding.(5) However, there is no clinical trial that examined heparin bridging at EMR.”
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BackgroundAnticoagulants and Antiplatelet Agents in Patients Undergoing Polypectomy
Milano, A., Laterza, F., Efthymakis, K., Bonitatibus, A., & Neri, M. (2017) · Springer eBooks · doi:10.1007/978-3-319-59457-6_9 · Cited by 1
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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