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


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


BOTTOM LINE
RÉSULTAT FINAL
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
DONNÉES PROBANTES
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. 
Context:  
  • 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


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Author(s)
Auteur(s)
  • 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

Comments:

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

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