No Additional Studies Are Needed—Current Evidence Provides Clear Guidance
The optimal anticoagulation management strategy for patients with atrial fibrillation undergoing surgery is already well-established: forgo bridging anticoagulation in most patients with nonvalvular AF, as bridging increases major bleeding without reducing thromboembolism. 1, 2
Evidence-Based Management Strategy
For Patients with Low to Moderate Thromboembolic Risk
Bridging anticoagulation should NOT be used in patients with nonvalvular AF who have a CHA₂DS₂-VASc score <7 or CHADS₂ score <5 undergoing elective procedures 1
The landmark BRIDGE trial (1,884 patients) definitively demonstrated that forgoing bridging was noninferior for preventing arterial thromboembolism (0.4% vs 0.3%) but superior for preventing major bleeding (1.3% vs 3.2%, P=0.005) 2
Multiple meta-analyses confirm this finding: bridging provides no reduction in stroke/systemic embolism (RR 1.25,95% CI 0.55-2.85) but significantly increases major bleeding risk (RR 3.29,95% CI 2.25-4.81) 3, 4
Warfarin Interruption Protocol (No Bridging)
Stop warfarin 5 days before the elective procedure 1
Resume warfarin within 24 hours after the procedure when adequate hemostasis is achieved 1
This approach is supported by the 2024 ESC Guidelines for cardiac surgery patients, which recommend uninterrupted oral anticoagulation for AF ablation procedures 5
For High-Risk Patients Requiring Bridging
Bridging with therapeutic-dose UFH or LMWH is indicated ONLY for: 1
- Mechanical heart valves
- Recent stroke or TIA (<3 months)
- Very high thromboembolic risk (CHA₂DS₂-VASc score ≥7 or CHADS₂ score 5-6)
- History of perioperative stroke
Bridging protocol when indicated:
- Start therapeutic-dose UFH or LMWH 3 days before procedure 1
- Stop 24 hours before procedure 1
- Resume 24-72 hours after procedure depending on bleeding risk 1
Direct Oral Anticoagulants (DOACs)
No bridging is required when interrupting DOACs 1
Timing of interruption depends on renal function and procedure bleeding risk 1
The 2024 ESC Guidelines recommend DOACs over VKAs when antiplatelet therapy is needed concomitantly, to mitigate bleeding risk 5
Why No Further Studies Are Needed
The evidence base is robust and consistent across multiple study designs:
High-quality RCT evidence: The BRIDGE trial provides Level 1 evidence with adequate power (1,884 patients) and clear outcomes 2
Confirmatory meta-analyses: Multiple systematic reviews including 13,808+ patients consistently show harm from bridging without benefit 3, 4
Guideline consensus: Both American College of Cardiology and 2024 ESC Guidelines provide clear, evidence-based recommendations 1, 5
Procedure-specific data: The PROSPECT cohort study demonstrated that bleeding risk varies by procedure extensiveness (0.7% for invasive procedures, 0% for minor surgery, 20% for major surgery), allowing risk stratification 6
Critical Pitfalls to Avoid
Do not bridge based solely on CHADS₂ score without considering the threshold: Most patients with AF (CHADS₂ <5) should NOT receive bridging 1, 2
Do not delay resumption of anticoagulation unnecessarily: Resume within 24 hours post-procedure when hemostasis permits, as delayed resumption increases thromboembolic risk 1
Do not perform inadequate risk assessment: The decision to bridge should be based on specific high-risk features (mechanical valves, recent stroke), not routine practice 1
Consider performing minor procedures without interrupting anticoagulation: Low bleeding-risk procedures can often be performed safely with continued anticoagulation 1