Education Blog for Healthcare Professionals

Warfarin Interruption for Surgery: Bridging with LMWH Often Not Needed

Stephan Moll, MD writes:  Interesting and relevant publication today in the New England Journal of Medicine (NEJM) [ref 1]: a large (1,884 patients), randomized, placebo-controlled, double-blind trial (called “BRIDGE trial”) of patients with atrial fibrillation on warfarin tested whether bridging with low molecular weight heparin (LMWH) is needed if warfarin is interrupted for an elective surgery or invasive procedure.  It is not – at least not in patients at mild or moderate risk for systemic thromboembolism (the mean CHADS-2 score in the study was 2.3; only 13.8 % had a CHADS-2 score of  ≥ 4).  The results show that bridging before and after the procedure led to more major bleeding than simple discontinuation and restarting of warfarin (3.2 % vs 1.3 %), yet the rate of arterial thromboembolism was statistically not different between the 2 groups (0.3 % vs 0.4 %).

Clinical Relevance

It has increasingly become clear that patients at low or moderate risk for thromboembolism –  either atrial fibrillation patients or venous thromboembolism (VTE) patients on warfarin – do not need LMWH bridging when warfarin is temporarily interrupted for surgical interventions [ref 2]. It leads to more bleeding, yet no benefit.  This publication confirms this (at least in respect to patients with atrial fibrillation) with this well structured and large study.  This is practice-changing.  However, in respect to VTE patients (which were not examined in this NEJM study): these patients may still need LMWH prophylaxis while restarting warfarin after a surgery that puts them at risk for VTE.

References

  1. Douketis JD et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl j Med, June 22, 2015.
  2. Siegal D et al. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation 2012;126:1630-9.

 

Disclosure: None

Last Updated: June 22, 2015

 

 

 

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