The BRIDGE trial: What the hospitalist should know

Abstract

Atrial fibrillation patients often require warfarin interruption for an invasive procedure or surgery. Heparin bridging therapy has been frequently used during warfarin interruption under the premise of providing a theoretical mitigation against thromboembolism that overweighs expected higher rates of bleeding. Up until recently, little definite clinical evidence was available to guide the hospitalist on optimal perioperative anticoagulant management. The landmark BRIDGE (Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation) trial provided high‐quality evidence that a simple interruption of warfarin in the average atrial fibrillation patient undergoing an elective procedure or surgery is noninferior to bridging therapy for efficacy and superior to bridging therapy in preventing major bleeding. To guide the hospitalist, we propose a treatment algorithm based on these recent data. We review the literature that led to the trial and highlight its practice‐changing implications as a proof of concept that calls to question the premise of heparin bridging therapy beyond the atrial fibrillation population. Journal of Hospital Medicine 2016;11:652–657. © 2016 Society of Hospital Medicine

Timing of Anticoagulation Resumption and Risk of Ischemic and Hemorrhagic Complications in Patients With ICH and Mechanical Heart Valves

“…Excluding the 2 patients with very late strokes, the median time off anticoagulation before stroke/TIA occurrence was 11 days (IQR 7-16). Time off anticoagulation was not associated with ischemic stroke or TIA occurrence (10 [6-17] without ischemic stroke or TIA vs 11 [10][11][12][13][14][15][16][17][18][19][20][21][22][23] with ischemic stroke or TIA) (p = 0.18). Most of the patients developed a stroke after being off anticoagulation for more than 7 days.…”

“…20 Similarly, a prospective, randomized, double-blind trial showed that simple interruption of warfarin in patients with atrial fibrillation who are undergoing an elective procedure or surgery is noninferior to bridging therapy for prevention of ischemic events and superior to heparin bridging for prevention of major bleeding. 21 Our study has notable strengths, including the large size of our cohort and the availability of long-term follow up. However, we acknowledge it also has limitations.…”