To Bridge or not To Bridge?

A Tale of Two Studies

Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery (BRIDGE) Trial

The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry

Two recent studies examine whether bridging with LMWH vs warfarin interruption without bridging is effective in reducing bleeding/thromboembolism in the perioperative period. 

In the noninferiority study, warfarin was stopped 5 days before surgery; LMWH was given 3 days and up until 24 hours before the planned procedure.

Conclusion: Forgoing bridging anticoagulation was noninferior to perioperative bridging with LMWH.

Caveats: Average CHADS₂ score 2.3 but overall risk of perioperative events was low. Is CHADS₂ score poor predictor? Do we overestimate perioperative hypercoagulable state?
 

ORBIT-AF: US-based prospective registry offered nonrandomized perspective on perioperative bridging outcomes.

Conclusions: Bridging anticoagulation is used in one quarter of anticoagulation interruptions and is associated with higher risk for bleeding and adverse events. 

Caveats: Significant variability in timing, dose, choice of drug for periprocedural bridging therapy-critical component of bleeding outcomes.

REFERENCES

Douketis JD, Spyropoulos AC, Kaatz S, et al for the BRIDGE Investigators. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med 2015; 373:823-833. DOI: 10.1056/NEJMoa1501035

Steinberg BA, Peterson ED, Sunghee S, et al. Use and Outcomes Associated With Bridging During Anticoagulation Interruptions in Patients With Atrial Fibrillation: Findings From the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation.2015; 131: 488-494. doi: 10.1161/CIRCULATIONAHA.114.011777