What is warfarin (anticoagulant) bridging therapy?

From the Guidelines

Warfarin bridging therapy is not necessary for most patients and may only be appropriate for those with a very high thromboembolic risk, as it increases the risk of bleeding without providing a significant benefit in preventing arterial thromboembolism, as shown in the 2019 AHA/ACC/HRS focused update on atrial fibrillation 1. The decision to use warfarin bridging therapy should be individualized, taking into account the patient's thromboembolic risk versus bleeding risk.

• The Warfarin Therapy for an Elective Invasive Procedure or Surgery study, a randomized, double-blind, placebo-controlled trial, found that absence of bridging was noninferior to bridging with low-molecular-weight heparin for prevention of arterial thromboembolism and decreased the risk of bleeding 1.
• Patients with a high thromboembolic risk, such as those with mechanical heart valves or recent venous thromboembolism, may still require bridging anticoagulation.
• The bridging process, when necessary, typically involves substituting a short-acting anticoagulant, such as low molecular weight heparin (LMWH), when a patient on long-term warfarin therapy needs to stop taking warfarin before a surgical procedure or invasive intervention.
• The choice of bridging therapy should be based on the patient's specific clinical situation and risk factors, rather than a one-size-fits-all approach.
• It is essential to weigh the benefits and risks of bridging therapy for each patient, considering factors such as the type of procedure, the patient's underlying medical conditions, and their individual risk of thromboembolism and bleeding.

From the Research

Definition of Warfarin Bridging Therapy

Warfarin bridging therapy refers to the use of a shorter-acting anticoagulant, such as low-molecular-weight heparin (LMWH), to maintain functional anticoagulation during the period when warfarin therapy is temporarily interrupted for an elective surgical or invasive procedure 2. This therapy is used to protect patients against thromboembolism while they are off warfarin.

Purpose of Bridging Therapy

The purpose of bridging therapy is to minimize the risk of thromboembolic events in patients who require temporary interruption of warfarin therapy for a procedure or surgery 3, 4. Bridging therapy is typically used for patients at intermediate to high risk of thromboembolism.

Types of Bridging Therapy

• Low-molecular-weight heparin (LMWH) is a common type of bridging therapy used for patients on long-term warfarin therapy 5, 6.
• Unfractionated heparin (UFH) is another type of anticoagulant that can be used for bridging therapy, although it is often administered in an inpatient setting 6.

Key Considerations

• The decision to use bridging therapy should be based on an assessment of the patient's risk factors for thrombosis and bleeding, as well as the type of procedure being performed 2.
• The timing and duration of bridging therapy should be carefully planned to minimize the risk of bleeding and thromboembolic events 3, 5.
• Patients should be closely monitored for signs of bleeding or thromboembolism during the bridging period 4, 6.

Efficacy and Safety

• Studies have shown that bridging therapy with LMWH can be effective in preventing thromboembolic events in patients on long-term warfarin therapy 3, 6.
• However, bridging therapy also carries a risk of bleeding, and the decision to use it should be made on a case-by-case basis 4, 5.