Is bridging anticoagulation necessary perioperatively in patients with non-valvular atrial fibrillation (AF)?

Until recently, there were no randomized-controlled trials (RCTs) available to help guide our decision.  A 2015 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).  

It’s important to keep in mind the ineligibility criteria in this study before you consider not bridging perioperatively.  The following were listed as exclusion criteria in this study:

  • 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 < 100,000/ cubic ml
  • Planned cardiac, intracranial, or intraspinal surgery.                                                                                                                                     

Another important caveat of the BRIDGE study is that it included relatively few patients (<5%) with CHADS-2 score >4.

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Reference

  1. 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).
Is bridging anticoagulation necessary perioperatively in patients with non-valvular atrial fibrillation (AF)?