What are the key findings and implications of the BRIDGE-TNK (Bridging with Antiplatelet Therapy or Anticoagulation in Patients with Atrial Fibrillation - TNK) trial on patient morbidity and mortality?

Key Findings and Implications of the BRIDGE-TNK Trial for Journal Club Presentation

Overview of the BRIDGE Trial

The BRIDGE trial demonstrated that forgoing bridging anticoagulation in patients with atrial fibrillation who require temporary warfarin interruption for elective procedures is not only noninferior for preventing thromboembolism but also significantly reduces major bleeding risk compared to bridging with low-molecular-weight heparin. 1

This landmark randomized, double-blind, placebo-controlled trial enrolled 1,884 patients with atrial fibrillation who required temporary interruption of warfarin therapy for elective procedures. The study has significant implications for perioperative management of anticoagulation in this patient population.

Study Design and Methodology

• Patient population: 1,884 patients with atrial fibrillation requiring temporary warfarin interruption
• Randomization: 950 patients to no bridging vs. 934 patients to bridging therapy
• Intervention:
  • No bridging group: placebo
  • Bridging group: dalteparin 100 IU/kg twice daily
• Timing: Bridging/placebo administered from 3 days before procedure until 24 hours before procedure, then resumed 5-10 days post-procedure
• Warfarin management: Stopped 5 days before procedure, resumed within 24 hours after procedure
• Follow-up period: 30 days post-procedure

Primary Outcomes and Results

Efficacy Outcome: Arterial Thromboembolism

• No bridging group: 0.4% incidence
• Bridging group: 0.3% incidence
• Risk difference: 0.1 percentage points (95% CI: -0.6 to 0.8)
• P=0.01 for noninferiority

Safety Outcome: Major Bleeding

• No bridging group: 1.3% incidence
• Bridging group: 3.2% incidence
• Relative risk: 0.41 (95% CI: 0.20 to 0.78)
• P=0.005 for superiority

Clinical Implications for Patient Management

Algorithm for Perioperative Anticoagulation Management:

1. For most patients with atrial fibrillation requiring temporary warfarin interruption:

   • Stop warfarin 5 days before procedure
   • No bridging anticoagulation needed
   • Resume warfarin within 24 hours after procedure

2. Exception: High-risk patients who may still benefit from bridging:

   • Recent (<3 months) stroke or TIA
   • CHA₂DS₂-VASc score ≥7 or CHADS₂ score of 5-6
   • Prior perioperative stroke
   • Mechanical heart valves (particularly older-generation or mitral position)

Impact on Morbidity and Mortality

The BRIDGE trial findings have significant implications for reducing iatrogenic harm in patients with atrial fibrillation. By demonstrating that avoiding bridging anticoagulation:

• Does not increase thromboembolic risk (morbidity and mortality)
• Significantly reduces major bleeding complications (by approximately 60%)
• Simplifies perioperative management
• Potentially reduces healthcare costs and resource utilization

Strengths and Limitations

Strengths:

• Large sample size (1,884 patients)
• Randomized, double-blind, placebo-controlled design
• Clear, clinically relevant outcomes
• Pragmatic approach applicable to real-world practice

Limitations:

• Limited follow-up period (30 days)
• Exclusion of highest-risk patients (mechanical heart valves, recent stroke)
• Single bridging agent used (dalteparin)
• Limited generalizability to non-elective procedures

Comparison with Other Evidence and Guidelines

The BRIDGE trial results align with the 2022 CHEST guidelines on perioperative management of antithrombotic therapy, which recommend against bridging for most patients with atrial fibrillation 2. The guidelines specifically suggest:

• No bridging for most atrial fibrillation patients
• Consider bridging only for highest-risk patients (CHA₂DS₂-VASc ≥7, recent stroke/TIA, prior perioperative stroke)

This represents a significant shift from previous practice patterns where bridging was commonly used despite limited evidence.

Common Pitfalls in Perioperative Anticoagulation Management

• Overuse of bridging anticoagulation in low-to-moderate risk patients, increasing bleeding risk without clear benefit
• Inadequate risk stratification - failing to identify truly high-risk patients who may benefit from bridging
• Poor timing of anticoagulation resumption - too early can increase bleeding, too late can increase thromboembolism
• Lack of standardized protocols - inconsistent approaches leading to confusion and errors

Conclusion for Journal Club Presentation

The BRIDGE trial provides high-quality evidence that fundamentally changed the standard of care for perioperative anticoagulation management in patients with atrial fibrillation. By demonstrating that a simple interruption strategy without bridging is both safe and associated with less bleeding, this trial has helped reduce unnecessary treatment and iatrogenic harm in this common clinical scenario.

When presenting this trial at journal club, emphasize how these findings have directly impacted clinical practice by providing a clear, evidence-based approach that improves patient safety while simplifying perioperative management.