BRIDGE Study Recommendations for Anticoagulation Management in Atrial Fibrillation Patients Undergoing Surgery
The BRIDGE trial (published in 2015, not 2012) demonstrated that forgoing bridging anticoagulation in atrial fibrillation patients undergoing elective surgery is noninferior to bridging with low-molecular-weight heparin for preventing arterial thromboembolism and significantly reduces major bleeding risk. 1
Key Findings from the BRIDGE Trial
The BRIDGE (Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation) trial was a randomized, double-blind, placebo-controlled study that enrolled 1,884 patients with atrial fibrillation requiring warfarin interruption for elective procedures 1. The study compared bridging therapy with dalteparin (100 IU/kg subcutaneously twice daily) versus placebo during the perioperative period 1.
Primary Outcomes
Arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) occurred in 0.4% of the no-bridging group versus 0.3% in the bridging group, demonstrating noninferiority (risk difference 0.1 percentage points; 95% CI, -0.6 to 0.8) 1
Major bleeding occurred in 1.3% of the no-bridging group versus 3.2% in the bridging group, showing superiority for the no-bridging approach (relative risk 0.41; 95% CI, 0.20 to 0.78; P=0.005) 1
Current Guideline Recommendations Based on BRIDGE Trial Evidence
The 2022 American College of Chest Physicians guidelines, incorporating BRIDGE trial data, recommend against routine bridging anticoagulation in most atrial fibrillation patients undergoing elective surgery. 2
For Standard-Risk Atrial Fibrillation Patients
No bridging anticoagulation is recommended for patients with atrial fibrillation without high thromboembolism risk (CHA₂DS₂-VASc score <7 or CHADS₂ score <5) 2, 3
The BRIDGE trial showed no bridging was noninferior to LMWH bridging for preventing arterial thromboembolism (0.3% vs 0.4%) but bridging conferred a threefold increased risk for major bleeding (3.2% vs 1.3%; OR 3.60; 95% CI: 1.52-8.50) 2
For High-Risk Patients Requiring Bridging
Bridging anticoagulation should be considered only in highly selected high-risk patients, including those with: 2, 3
- Recent stroke or TIA (within 3 months)
- CHA₂DS₂-VASc score ≥7 or CHADS₂ score of 5-6
- History of perioperative stroke
- Mechanical heart valves (particularly mitral valves or older-generation tilting-disc valves)
Perioperative Management Protocol
Warfarin Interruption Timeline
Check INR the day before surgery, with target INR ≤1.4-1.5 for safe surgery 2
Resume warfarin within 24 hours after the procedure when adequate hemostasis is achieved 3, 1
Bridging Protocol (When Indicated)
Start therapeutic-dose LMWH or unfractionated heparin 3 days before the procedure 2, 3, 1
Administer only the morning dose on the day before surgery 2, 1
Resume bridging 24-72 hours after the procedure, depending on bleeding risk, and continue for at least 5 days post-operatively until INR is ≥2.0 2, 1
Critical Pitfalls to Avoid
The most common error is over-bridging patients at low to moderate thromboembolism risk, which unnecessarily increases bleeding complications without reducing stroke risk 2, 1, 4. Meta-analyses confirm bridging is associated with significantly higher major bleeding (risk ratio 3.29; 95% CI: 2.25-4.81) with no difference in stroke/systemic embolism (risk ratio 1.25; 95% CI: 0.55-2.85) 4.
Inadequate risk stratification leads to inappropriate bridging decisions 3. Use the CHA₂DS₂-VASc score systematically to identify the minority of patients who truly require bridging 2, 3.
Delayed resumption of anticoagulation unnecessarily increases thromboembolic risk 3. Resume warfarin within 24 hours post-procedure when hemostasis permits 3, 1.