#11 Atrial Fibrillation Patients Needing Brief Interruptions in Warfarin: Bridge or Not?
CLINICAL QUESTION
If non-valvular atrial fibrillation (AF) patients on warfarin require an interruption of warfarin, should we bridge with a heparin product?
BOTTOM LINE
Non-valvular AF patients on warfarin at lower risk of thromboembolism (CHADS2 score ≤3) do not require bridging for brief interruptions <7 days. Bridging is still recommended with higher risk (example CHADS2 score >4, recent stroke/TIA, rheumatic valve disease or mechanical valves).
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EVIDENCE
BRIDGE trial:1 Randomized Controlled Trial (RCT) of 1,884 patients on warfarin for AF/flutter going for elective procedure requiring warfarin interruption.
- Mean age 72 years, CHADS2 score 2.4 (<15% >4).
- Bridging with therapeutic dalteparin versus placebo started three days before surgery and restarted post-operative day 0-1 for 5-10 days.
- Higher risk of major bleed (3.2% versus 1.3%), Number Needed to Harm (NNH)=53.
- No significant difference at day 30-37 in:
- Death: 0.4% versus 0.5%.
- Thromboembolic events: 0.4% versus 0.3%.
- 44% of patients had AF (rest were prosthetic valves, venous thromboembolism, etc.) undergoing wide variety of procedures.
- Outcomes at 30-day follow-up for bridge versus non-bridged:
- Major bleed: 4.2% versus 0.9%.
- Thromboembolism: 0.9% versus 0.6%.
- Limitations: 33/34 studies not randomized.
- For some procedures, continuing warfarin may be safer than bridging (example tooth extraction, cataract surgery).3
- RCT4 of 681 patients undergoing cardiac device surgery (considered high-bleeding-risk) with moderate-to-high risk of thromboembolism (example AF with CHADS2 ≥3, prosthetic valve).
- Clinically significant hematoma:
- Continued warfarin 3.5% versus bridging 16%.
- No difference in thromboembolic events.
- Clinically significant hematoma:
- Observational evidence suggests other procedures may be managed with warfarin continuation (example AF ablation,5,6 elective coronary angiography7).
- RCT4 of 681 patients undergoing cardiac device surgery (considered high-bleeding-risk) with moderate-to-high risk of thromboembolism (example AF with CHADS2 ≥3, prosthetic valve).
- Canadian AF guidelines,8 published before BRIDGE trial results:
- Low-bleed-risk procedure: No interruption required.
- Intermediate-to-high risk procedure: Interrupt warfarin x5 days to get INR <1.2 for procedure and restart after hemostasis established (usually ~24 hours)
- Low stroke risk (CHADS2 ≤2-3): No bridging.
- Moderate-to-high stroke risk (CHADS2 ≥3-4, recent stroke/TIA, rheumatic valve disease, mechanical valve): Bridge.
- American College of Chest Physicians’ recommendations9 and other reviews10,11 are similar.
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