Perioperative bridging anticoagulation in patients with atrial fibrillation.

Perioperative management of anticoagulation is sometimes complex and challenging. Different factors influencing the balance between the risk of thrombosis and the bleeding risk should be considered. Since all patients do not have the same co-morbidities and do undergo the same surgical procedures, both patient-related and surgery-related factors should be considered. Although bridging strategies have been discussed over recent years, no consensus recommendations have been provided. Different studies have recently compared the incidences of thrombosis and bleeding with and without bridging, showing a strong signal that bridging therapy is associated with a significantly increased bleeding risk, while the absence of bridging was not associated with any increase in the incidence of thromboembolic complications.

The BRIDGE study is a large prospective, randomised study in which over 1800 patients with atrial fibrillation treated with warfarin received either low-molecular-weight heparin (LMWH) or placebo before an elective surgical procedure. The study sought to compare the incidence of thromboembolic complications and bleeding associated with both strategies. The incidence of arterial thromboembolism was low in both groups (0.3% in the bridging group compared with 0.4% in the no-bridging group), supporting the non-superiority hypothesis for preoperative bridging (P = 0.73). However, the incidences of major bleeding (3.2% vs. 1.3%; P = 0.005) and minor bleeding (20.9% vs. 12.0%; P < 0.001) were significantly higher in the bridging group compared to controls. The results of this large prospective study, in addition to those of other recent studies, confirm that bridging therapy might not be beneficial in the vast majority of the patients with atrial fibrillation who are treated with oral anticoagulants. However, we need to keep in mind that these studies did not focus on extremely high-risk populations, and further sub-analyses are probably needed to identify the minority of high-risk patients that would benefit from a bridging strategy. – David Faraoni