Credits Earned (2024) Crédits obtenus

Redeem Prepaid Membership

Tools for Practice Outils pour la pratique

#11 Atrial Fibrillation Patients Needing Brief Interruptions in Warfarin: Bridge or Not?

If non-valvular atrial fibrillation (AF) patients on warfarin require an interruption of warfarin, should we bridge with a heparin product?

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).

CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session

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%. 
Systematic review2 of 34 studies including 7,118 bridged and 5,160 non-bridged patients. 
  • 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. 
    • Observational evidence suggests other proceduremay be managed with warfarin continuation (example AF ablation,5,6 elective coronary angiography7). 
  • 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. 
updated by ricky july 20 2016

Latest Tools for Practice
Derniers outils pour la pratique

#367 Oral Calcitonin Gene-related Peptide Antagonists: A painfully long name for the acute treatment of migraines

What are the risks and benefits of ubrogepant for the acute treatment of episodic migraines?
Read Lire 0.25 credits available Crédits disponibles

#366 Looking for Closure: Managing simple excisions or wounds efficiently

What are some options for efficiency in wound closure?
Read Lire 0.25 credits available Crédits disponibles

#365 Shrooms for Glooms: Evidence for psilocybin for depression

What are the benefits and harms of psilocybin for treatment-resistant/recurrent depression?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session

  • G. Michael Allan MD CCFP
  • Ricky D. Turgeon BSc(Pharm) ACPR PharmD

1. Douketis JD, Spyropoulos AC, Kaatz S, et al. N Engl J Med. 2015; 373:823-33.

2. Siegal D, Yudin J, Kaatz S, et al. Circulation. 2012; 126:1630-9.

3. Dunn AS, Turpie AG. Arch Intern Med. 2003; 163:901-8.

4. Birnie DH, Healey JS, Wells GA, et al. N Engl J Med. 2013; 368:2084-93.

5. Kuwahara T, Takahashi A, Takahashi Y, et al. J Cardiovasc Electrophysiol. 2013; 24:510-5.

6. Santangeli P, Di Biase L, Horton R, et al. Circ Arrhythm Electrophysiol. 2012; 5:302-11.

7. Jamula E, Lloyd N, Schwalm JD, et al. Chest. 2010; 138:840-7.

8. Verma A, Cairns JA, Mitchell B, et al. Can J Cardiol. 2014; 30:1114-30.

9. Douketis JD, Spyropoulos AC, Spencer FA, et al. Chest. 2012; 141:e326S-e350S.

10. Baron TH, Kamath PS, McBane RD. N Engl J Med. 2013; 368:2113-24.

11. Healey JS, Brambatti M. Can J Cardiol. 2013; 29(7 Suppl)S54-9.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.

Most recent review: 20/07/2016

By: Ricky Turgeon BSc(Pharm) ACPR PharmD


Evidence Updated: New evidence; Bottom Line: No change.

Learning at a glance
Yearly credits
Acquired ()
Your content by topic
Cardiology Dermatology Emergency
My Bookmarks