Cited by 1,184Atrial Fibrillation Management and OutcomesVenous Thromboembolism Diagnosis and ManagementBlood Coagulation and Thrombosis Mechanisms

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Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

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Douketis, James D., Spyropoulos, Alex C., Kaatz, Scott, Becker, Richard C., Caprini, Joseph A., Dunn, Andrew S., Garcia, David A., Jacobson, Alan, Jaffer, Amir K., Kong, David F., Schulman, Sam, Turpie, Alexander G.G., Hasselblad, Vic, Ortel, Thomas L.·2015·New England Journal of Medicine

DOI 10.1056/nejmoa1501035PMC PMC4931686

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Abstract

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 these patients, it was found that forgoing heparin bridging therapy was not only noninferior to bridging but that it also decreased the risk of major bleeding.(61) The risk of bleeding has also been shown to be increased in patients on NOACs who undergo heparin bridging.”
Background
The preparation of patients taking anticoagulants for endoscopic procedures
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Anticoagulant-Free but Dangerous: Perisurgical Consideration
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Intracranial hemorrhage associated with direct oral anticoagulant developing at three days after clipping for unruptured cerebral aneurysm through craniotomy
Matsumoto, Y., Kubo, Y., Koji, T., Yoshida, J., & Ogasawara, K. (2017) · Nosotchu · doi:10.3995/jstroke.10530
Terapia puente en los pacientes anticoagulados: ¿todavía esa es la cuestión?
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Antithrombotics: Anticoagulants Including NOACs
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Highlights from the Ninth International Symposium of Thrombosis and Anticoagulation (ISTA IX), October 15, 2016, Salvador, Bahia, Brazil
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“To bridge or not to bridge”: Is it still the question?
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Navigating the anticoagulant landscape in 2017
Douketis, J. D. (2017) · Cleveland Clinic Journal of Medicine · doi:10.3949/ccjm.84gr.17005
Kommentar zum periprozeduralen Management der Antikoagulation
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The Patient with Haemorrhagic Risk
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Clopidogrel Therapy in Patients with Cardiovascular Disease Undergoing Transurethral Resection of the Prostate: A Step Towards Individualization
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Patient’s Own Risk Factors
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Anästhesie bei Patienten mit Erkrankungen der Herzklappen
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Perioperatives Management bei antikoagulierten Patienten
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“zur Überbrückung der oralen Antikoagulation – ein erhöhtes Blutungsrisiko besteht, ohne dass es zu einer Reduktion periprozedualer thrombembolischer Ereignisse kommt [14].”
Therapeutic Advances in the Perioperative Period for Older Adults
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Periprocedural Bridging Anticoagulation
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Skills, Practice Patterns, and Knowledge of Canadian Family Physician Endoscopists
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Anticoagulants and Therapeutic Endoscopy
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Therapeutic anticoagulation for pulmonary embolism during first-trimester surgical abortion: two case reports
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“However, the first randomized controlled trial addressing perioperative anticoagulation in patients with this disorder showed that not only does bridging therapy not decrease the risk for stroke, it significantly increases the risk for major bleeding for patients at moderate risk for stroke (3).”
Background

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: Douketis, James D.
Spyropoulos, Alex C.
Kaatz, Scott
Becker, Richard C.
Dunn, Andrew S.
Garcia, David A.
Jaffer, Amir K.
Schulman, Sam
Ortel, Thomas L.
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
DOI: 10.1056/nejmoa1501035
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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Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

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