Home > Journal Club > Journal Club 15 July 2015

Journal Club 15 July 2015

Paper

Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

Presenter

KK

Summary

BACKGROUND

It is uncertain whether bridging anticoagulation is necessary for patients with
atrial fibrillation who need an interruption in warfarin treatment for an elective
operation or other elective invasive procedure. We hypothesized that forgoing
bridging anticoagulation would be noninferior to bridging with low-molecularweight
heparin for the prevention of perioperative arterial thromboembolism and
would be superior to bridging with respect to major bleeding.

METHODS

We performed a randomized, double-blind, placebo-controlled trial in which, after
perioperative interruption of warfarin therapy, patients were randomly assigned
to receive bridging anticoagulation therapy with low-molecular-weight heparin
(100 IU of dalteparin per kilogram of body weight) or matching placebo administered
subcutaneously twice daily, from 3 days before the procedure until 24 hours
before the procedure and then for 5 to 10 days after the procedure. Warfarin treatment
was stopped 5 days before the procedure and was resumed within 24 hours
after the procedure. Follow-up of patients continued for 30 days after the procedure.
The primary outcomes were arterial thromboembolism (stroke, systemic embolism,
or transient ischemic attack) and major bleeding.

RESULTS

In total, 1884 patients were enrolled, with 950 assigned to receive no bridging
therapy and 934 assigned to receive bridging therapy. The incidence of arterial
thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging
group (risk difference, 0.1 percentage points; 95% confidence interval [CI], −0.6 to
0.8; P = 0.01 for noninferiority). The incidence of major bleeding was 1.3% in the
no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI,
0.20 to 0.78; P = 0.005 for superiority).

CONCLUSIONS

In patients with atrial fibrillation who had warfarin treatment interrupted for an
elective operation or other elective invasive procedure, forgoing bridging anticoagulation
was noninferior to perioperative bridging with low-molecular-weight
heparin for the prevention of arterial thromboembolism and decreased the risk of
major bleeding.

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