Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation.

Abstract

Each year approximately one in six patients with atrial fibrillation (AF) treated with Vitamin K antagonists (VKAs) requires to undergo an elective surgery or procedure. It is uncertain whether bridging anticoagulation during VKA interruption is needed. VKA interruption without bridging may increase the risk of thrombo-embolism. Bridging during VKA interruption may increase the risk of bleeding. Recently, a randomized, double-blind, placebo-controlled trial was published: the "Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery" (BRIDGE) trial. This trial indicates that in patients with AF who require a perioperative interruption of warfarin treatment for an elective procedure, a strategy of discontinuing warfarin treatment without the use of bridging anticoagulation was at least as good as the use of bridging anticoagulation in preventing thromboembolism. In addition, bridging conferred a risk of major bleeding that was nearly triple the risk associated with no bridging. Following these results, a strategy of no bridging anticoagulation during warfarin interruption is preferable. Whether this conclusion holds during the interruption of other VKAs (acenocoumarol, fenprocoumon), is uncertain. Patients with AF and mechanical valves were not studied. Patients with a very high CHADS2 score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, history of stroke or transient ischemic attack for thromboembolism) ≥ 5 were underrepresented in the trial. Until proven otherwise in both of these last groups, bridging anticoagulation remains the preferred strategy. According to the European guidelines, patients with AF requiring an interruption of a treatment with novel oral anticoagulants (NOACs) do not need bridging anticoagulation.