No anticoagulation bridging for elective procedures offers benefits

Here’s a bridge you may consider burning: anticoagulation bridging therapy for patients with atrial fibrillation who undergo an elective operation. A randomized clinical trial found no bridging after discontinuing warfarin led to no more thromboembolic events than bridging, with a lower risk of bleeding.

The results were published online June 22 in the New England Journal of Medicine.

James D. Douketis, MD, of St. Joseph’s Healthcare Hamilton in Hamilton, Ontario, and members of the BRIDGE trial (Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure for Surgery) designed the randomized, double-blind, placebo-controlled trial to assess the need for bridging anticoagulation in patients with permanent or paroxysmal atrial fibrillation or flutter who undergo an operation or invasive procedure. Patients may need to interrupt warfarin treatment in these circumstances, and some physicians fear that will lead to perioperative arterial thromboembolism.

The trial enrolled 1,884 patients between 2009 and 2014 at 108 sites in the U.S. and Canada and randomized them to receive either a placebo or dalteparin, a low-molecular weight heparin. They stopped warfarin five days before their procedure and resumed treatment within 24 hours after their procedure. The primary efficacy outcome was arterial thromboembolism and the primary safety outcome was major bleeding.

The incidence of arterial thromboembolism was 0.4 percent in the control group vs. 0.3 percent in the bridging group. The rate of major bleeding was 1.3 percent in the control group vs. 3.2 percent in the bridging group and the risk of minor bleeding was 12 percent vs. 20.9 percent. There also was no difference in MI, venous thromboembolism or death between the groups.

The results supported the BRIDGE study researchers’ hypothesis that no bridging would be noninferior to the use of low-molecular weight heparin bridging, with a decreased risk of bleeding. “Taken together, these findings show that there is a net clinical benefit in favor of a strategy of forgoing bridging, as compared with perioperative bridging with low-molecular weight heparin,” they wrote.

They acknowledged that the trial did not represent some patient groups, including those who undergo surgical procedures with high thromboembolism rates and bleeding, but they did represent the most common procedures.