In which patients with atrial fibrillation (AF) do you use a heparin bridge?

From the Guidelines

Heparin bridging is not recommended for most patients with atrial fibrillation (AF) who require interruption of oral anticoagulation for procedures, as the risk of bleeding outweighs the benefit of thromboembolism prevention, except in patients with a very high thromboembolic risk. The decision to use heparin bridging in patients with AF should be based on the individual patient's risk of thromboembolism and bleeding.

• The BRIDGE trial 1 and the 2019 AHA/ACC/HRS focused update 1 suggest that bridging anticoagulation may be appropriate only in patients with a very high thromboembolic risk, such as those with:
  • Mechanical heart valves
  • Recent stroke or TIA (within 3 months)
  • Rheumatic valvular heart disease
  • CHADS2 score ≥4
• The bridging protocol may include:
  • Stop warfarin 5 days before procedure
  • Start low molecular weight heparin (e.g., enoxaparin 1 mg/kg twice daily) when INR <2
  • Stop heparin 24 hours before procedure
  • Resume heparin 24 hours after procedure if hemostasis is adequate
  • Restart warfarin when oral intake is possible However, the most recent and highest quality study, the BRIDGE trial 1, showed that no bridging was noninferior to LMWH for the outcome of ATE, but bridging conferred a threefold increased risk for major bleeding, which supports the recommendation to avoid bridging in most patients. It's essential to carefully weigh the risks and benefits of heparin bridging for each patient, considering their individual risk factors and the potential consequences of thromboembolism and bleeding.

From the Research

Heparin Bridge in Atrial Fibrillation Patients

The use of a heparin bridge in patients with atrial fibrillation (AF) is a topic of ongoing debate. According to the available evidence, the decision to use a heparin bridge depends on various factors, including the patient's stroke and bleeding risk.

Patient Selection

• Patients with AF who are at high risk of stroke and bleeding may benefit from oral anticoagulant therapy, including the use of a heparin bridge 2.
• However, the BRIDGE trial found that 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 in patients with AF who had warfarin treatment interrupted for an elective operation or other elective invasive procedure 3.
• The choice of oral anticoagulant, including the use of a heparin bridge, depends on various patient characteristics, such as age, renal dysfunction, coronary artery disease, and risk of bleeding 4.

Bleeding Risk

• The risk of major bleeding is a significant concern in patients with AF, particularly in those with a history of bleeding or at high risk of bleeding 2, 4.
• The use of a heparin bridge may increase the risk of major bleeding, particularly in patients with a high risk of bleeding 3, 5.

Alternative Strategies

• Minimally interrupted or uninterrupted non-vitamin K antagonist oral anticoagulants (NOACs) may be a viable alternative to a heparin bridge in patients with AF undergoing ablation or other procedures 5.
• The choice of oral anticoagulant and the decision to use a heparin bridge should be individualized based on the patient's specific risk factors and clinical characteristics 2, 4.