When is bridging to anticoagulation (Anticoagulant therapy) recommended?

Bridging Anticoagulation: Indications and Management

Bridging anticoagulation therapy is recommended for patients at high risk of thromboembolism who require temporary interruption of oral anticoagulants for invasive procedures, while patients at low thrombotic risk should not receive bridging therapy. 1

Risk Stratification for Bridging Therapy

High Thrombotic Risk (Bridging Recommended)

• Mechanical mitral valve replacement 1
• Older-generation mechanical aortic valve replacement 1
• Mechanical aortic valve with additional risk factors for thromboembolism 1
• Recent venous thromboembolism (<3 months) 2
• Severe thrombophilia 2
• Atrial fibrillation with CHA₂DS₂-VASc score >5 2
• Antiphospholipid syndrome with high-risk features 2

Low Thrombotic Risk (No Bridging Recommended)

• Bileaflet mechanical aortic valve without additional risk factors 1
• Atrial fibrillation with CHA₂DS₂-VASc score ≤5 2
• Venous thromboembolism >3 months ago 2
• Most thrombophilias 2
• Stable coronary artery disease 2

Procedures Not Requiring Anticoagulation Interruption

For certain low bleeding risk procedures, continuation of vitamin K antagonist (VKA) therapy is recommended:

• Minor dental procedures 1
• Cataract surgery 1
• Minor dermatologic procedures 1
• Other procedures where bleeding is easily controlled 1

Bridging Protocol for High-Risk Patients

1. Pre-procedure management:

   • Stop VKA 5 days before procedure 1
   • Start LMWH 2-3 days after stopping VKA when INR becomes subtherapeutic 2
   • Administer last dose of LMWH at least 24 hours before procedure 2

2. Post-procedure management:

   • Resume VKA evening of or day after procedure at usual dose 2
   • For low bleeding risk procedures: Resume LMWH 24 hours after procedure 2
   • For high bleeding risk procedures: Delay LMWH for 48-72 hours 2
   • Continue LMWH until INR reaches therapeutic range 1

Management for Low-Risk Patients

1. Pre-procedure management:

   • Stop VKA 5 days before procedure 1
   • Check INR before procedure to ensure it's <1.5 2
   • No bridging anticoagulation needed 1

2. Post-procedure management:

   • Resume VKA 12-24 hours after procedure (evening of or next morning) 1
   • No LMWH needed 2

Emergency Surgery Considerations

For patients with mechanical valve prosthesis requiring immediate/emergency surgery:

• Administration of 4-factor prothrombin complex concentrate (or its activated form) is reasonable 1
• Fresh frozen plasma if PCC is not available 1

Special Considerations

Atrial Fibrillation with Bioprosthetic Heart Valves

• Consider bridging based on CHA₂DS₂-VASc score weighed against bleeding risk 1

Gastrointestinal Procedures

• For patients with high thrombotic risk who experience GI bleeding, early resumption of anticoagulation (within 3 days) is recommended 1
• For patients with low thrombotic risk, restart anticoagulation after 7 days 1

Direct Oral Anticoagulants (DOACs)

• DOACs have shorter half-lives and typically don't require bridging therapy 2
• Withhold DOACs 24-48 hours before procedures depending on bleeding risk and renal function 2

Important Caveats

• Bridging therapy increases bleeding risk without reducing thromboembolic events in most patients 2
• The BRIDGE trial demonstrated that for most atrial fibrillation patients, no bridging was non-inferior to bridging with LMWH for prevention of arterial thromboembolism and significantly decreased bleeding risk 2
• Prolonged overlap of warfarin and other anticoagulants presents significant bleeding risks 2
• For patients with mechanical heart valves, the risk-benefit assessment should be carefully considered, as thromboembolism prevention may outweigh bleeding risk in high-risk valves 1

By following these evidence-based recommendations, clinicians can optimize perioperative anticoagulation management to minimize both thrombotic and bleeding complications.