When to use heparin bridging in patients with atrial fibrillation (AF) on warfarin (Coumadin) who require temporary cessation of warfarin for a procedure?

From the Guidelines

Heparin bridging should not be routinely used in patients with atrial fibrillation on warfarin who require temporary cessation of anticoagulation for procedures, as it increases bleeding risk without significantly reducing thromboembolic events, as shown in the BRIDGE trial 1. The decision to bridge should always balance thromboembolic risk against procedural bleeding risk, with consideration of patient-specific factors such as renal function, age, and history of bleeding complications. For most AF patients, the bleeding risks outweigh the benefits of bridging, and it is generally recommended only for patients at high thromboembolic risk, specifically those with a CHA2DS2-VASc score ≥ 5, recent stroke or TIA within 3 months, or mechanical heart valves. When bridging is indicated, low molecular weight heparin (LMWH) such as enoxaparin is preferred, typically at a therapeutic dose of 1 mg/kg twice daily. Warfarin should be stopped 5 days before the procedure, with LMWH starting when the INR falls below 2.0, usually 2-3 days before the procedure. LMWH should be stopped 24 hours before the procedure and resumed 24-72 hours after, depending on bleeding risk. Warfarin can be restarted the evening of or day after the procedure at the patient's usual maintenance dose. Recent guidelines also suggest that for patients on non-vitamin K antagonist oral anticoagulants (NOACs), bridging is not recommended or necessary unless a longer period of interruption occurs 1. In patients with atrial fibrillation undergoing percutaneous coronary intervention, the use of bridging anticoagulation with low-molecular-weight heparin is not recommended, and the decision to bridge should be individualized based on the patient's thromboembolic and bleeding risk 1. The 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation also recommends that decisions about bridging therapy should balance the risks of stroke and bleeding 1. Overall, a selective approach to heparin bridging is recommended, taking into account the individual patient's risk factors and the specific procedure being performed.

From the FDA Drug Label

When discontinuing warfarin sodium tablets even for a short period of time, the benefits and risks should be strongly considered. Some dental or surgical procedures may necessitate the interruption of warfarin sodium tablets therapy

The decision to use heparin bridging in patients with atrial fibrillation (AF) on warfarin who require temporary cessation of warfarin for a procedure depends on the individual patient's risk factors and the type of procedure being performed.

• The drug label does not provide a clear answer to this question, but it does suggest that the benefits and risks of discontinuing warfarin should be strongly considered.
• In general, heparin bridging may be considered for patients at high risk of thromboembolic events, such as those with a history of stroke or transient ischemic attack.
• However, the use of heparin bridging should be individualized based on the patient's specific clinical situation and risk factors 2, 2.

From the Research

Heparin Bridging in Atrial Fibrillation Patients on Warfarin

• The need for heparin bridging in patients with atrial fibrillation (AF) on warfarin who require temporary cessation of warfarin for a procedure is a common clinical dilemma.
• Studies have shown that the use of heparin bridging in these patients does not necessarily reduce the risk of thromboembolic events, but may increase the risk of bleeding 3, 4.
• A meta-analysis of 13,808 patients with AF found that periprocedural heparin bridging was associated with a higher rate of major bleeding, but no significant difference in mortality or cerebrovascular accidents compared to no bridging 4.
• The BRIDGE trial, a landmark study, found that simple interruption of warfarin in the average AF patient undergoing an elective procedure or surgery is noninferior to bridging therapy for efficacy and superior to bridging therapy in preventing major bleeding 5.
• Another study found that among AF patients with intermediate CHADS2 scores who are anticoagulated with warfarin and who required temporary interruption of warfarin for an elective surgery or procedure, periprocedural bridging with unfractionated heparin (UH) or low-molecular-weight heparin (LMWH) was associated with a higher rate of major bleeding with no significant difference in mortality or cerebrovascular accidents 4.
• The decision to use heparin bridging should be individualized, taking into account the patient's risk of thromboembolism and bleeding, as well as the type of procedure being performed 6, 7.

Factors to Consider

• The CHADS2 score, which estimates the risk of stroke in AF patients, can help guide the decision to use heparin bridging 3, 4.
• The type of procedure being performed, such as a high-bleeding-risk procedure, may also influence the decision to use heparin bridging 6.
• The use of bridging anticoagulation has been associated with a lower risk of major bleeding in patients with a higher time in therapeutic range (TTR) after interruption of warfarin 7.