Perioperative Bridging Anticoagulation in

Patients with Atrial Fibrillation

The New England Journal of Medicine
Douletis J.D., Spyopoulos A.C., Kaatz S., et al. (2015)
Background
The need for bridging anticoagulation in patients with Atrial
Fibrillation (AF) on warfarin during perioperative interruption is
uncertain.
Traditionally the rationale for use of bridging anticoagulation
therapy is built on the premise that the associated higher
bleeding risk was clinically acceptable due to the subsequent
lower risk of perioperative arterial thromboembolism with
therapeutic anticoagulation for AF.
Methods
The BRIDGE trial (Bridging Anti-coagulation in Patients who Require
Temporary Interruption of Warfarin Therapy for an Elective Invasive
Procedure or Surgery) performed a randomized, double-blind,
placebo-controlled trial.
Patients were randomly assigned to either receive bridging
anticoagulation with Low-Molecular Weight Heparin (LMWH) i.e.
daltaperin or a matching placebo:
-

Warfarin was stopped 5 days prior to the procedure and

restarted on the evening or day after
The study drug (daltaperin or placebo) was started 3 days
before the procedure, last dose given 24hours before the
procedure and then restarted 12-24 hours after a minor
(low bleeding risk) procedure or 48-72 hours after a major
(high bleeding risk) procedure

Study outcomes:
1) Primary efficacy outcome: Arterial thromboembolism at 30
days- Hypothesized that forgoing bridging anticoagulation
would be noninferior to bridging with LMWH
2) Primary safety outcome: Major bleeding Hypothesized that
forgoing bridging anticoagulation would be superior to
bridging with LMWH

Results
1) Arterial thromboembolism:
Incidence of 0.4% (4 of the 918) patients in no-bridging group
vs 0.3% (3 of the 895) patients in the bridging group (P=0.01
for noninferiorty)
- Patients who had arterial thromboembolism had a mean
CHADS2 score of 2.6
- 5 of the 7 had it after a minor procedure
2) Major bleeding
1.3% (12 of 918) patients in no bridging group vs 3.2% (29 of
895) in bridging group (P=0.005)
Also of note: Forgoing bridging was associated with a risk of
minor bleeding that was significantly lower than the risk
associated with bridging (12.0% vs 20.9%, P<0.001)
Conclusion
Forgoing bridging anticoagulation is noninferior in prevention of
arterial thromboembolism and that the risk of major bleeding is
nearly triple with bridging in patients with atrial fibrillation who
require perioperative interruption of warfarin treatment for an
elective procedure.
Caveats
1) Mean CHADS2 score was 2.3 in no-bridging and 2.4 in bridging
group, with over 86% in both groups having hypertension
2) 1/3 of the patients had congestive heart failure
3) About 35% of patients in both groups were on long term
aspirin use which was not controlled for in this study
4) Mean age was ~ 71, mean weight ~95 kg and about a 73%
male dominance . Also of note 90% of the study population
was of white ethnicity
Take Home Message:
It would be prudent to consider no-bridging anticoagulation in AF
patients who fit a similar profile to this study, i.e. an elderly, white
male with a CHADS2 score of about 2-3 and a past medical history of
hypertension so as to reduce the risk of bleeding without forgoing
an increase risk in arterial thromboembolism.