Until recently, there were no randomized-controlled trials (RCTs) available to help guide our decision. A recent RCT, however, demonstrated that foregoing bridging anticoagulation was not inferior to bridging with low-molecular-weight heparin in patients with chronic or paroxysmal AF for the prevention of arterial thromboembolism and decreased the risk of major bleeding (1). Ineligibility criteria included mechanical valve; stroke, systemic embolism, or transient ischemic attack within the previous 12 weeks; major bleeding within the previous 6 weeks; creatinine clearance < 30 ml/min; platelet count < 100K/ cubic ml; or planned cardiac, intracranial, or intraspinal surgery. A caveat is that the study included relatively few patients (<5%) with CHADS2 score >4.
Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med 2015 (published June 22 at NEJM.org).