Anticoagulation Bridging Unnecessary in Surgical AF Patients

Researchers at Duke University Medical Center (Duke; Durham, NC, USA) conducted a randomized trial in which 1,884 patients who interrupted warfarin therapy before surgery were randomly assigned to receive bridging anticoagulation with low-molecular-weight heparin, or matching placebo. Follow-up of the patients continued for 30 days after the procedure. The primary outcomes were arterial thromboembolism (TE), as manifested by stroke, systemic embolism, or transient ischemic attack (TIA), and major bleeding.

In total, 950 patients were assigned to receive no bridging therapy, while 934 were assigned to receive bridging therapy. The incidence of arterial TE was 0.4% in the no-bridging group, and 0.3% in the bridging group, while the incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group. The researchers stressed that the findings are specific to patients with AF who take warfarin, and should not be generalized. The study was published on June 22, 2015, in the New England Journal of Medicine (NEJM).

“Bridging does not improve the outcome for stroke prevention, but increases the risk of major bleeding complications. That's the counter balance - we're not doing patients any good, and we are potentially hurting them,” said senior author Thomas Ortel, MD, PhD, chief of the division of hematology at Duke. “This is the first study to provide high-quality clinical trial data demonstrating that for patients with atrial fibrillation who need a procedure and who need to come off warfarin, they can simply stop and restart; they do not need to be bridged.”

Current practice calls for AF patients to halt warfarin therapy for five days before and after they undergo an elective procedure, because it can cause dangerous bleeding and slow healing. After the procedure and resuming warfarin, it may take five or more days before the anticoagulant reaches its effective target therapeutic level. To continue protecting the surgical patients from TE during this intermission period, many doctors prescribe low-molecular weight heparin as a "bridging" therapy.

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