Is bridging therapy for anticoagulation (anticoagulant) successful?

From the Guidelines

Bridging therapy for anticoagulation should be limited to patients with very high thrombotic risk, such as those with mechanical mitral valves, due to the increased risk of bleeding without a significant benefit in lowering thromboembolism. The decision to use bridging therapy should be based on individual patient risk factors, including thrombotic risk and bleeding risk, as assessed by tools such as HAS-BLED and consideration of previous personal bleeding history and perioperative bleeding risk 1.

Key Considerations

• The PERIOP-2 study, which enrolled 1471 patients on VKA requiring noncardiac surgery, found that thromboembolism was similar across all patient populations, and secondary outcomes of bleeding were increased with postoperative bridging 1.
• Current evidence suggests that bridging is most beneficial for patients with high thrombotic risk, but the majority of results are based on poor-quality cohorts overall 1.
• The risk-benefit assessment should be individualized, weighing the patient's thrombotic risk against their bleeding risk for the specific procedure they're undergoing.

Bridging Regimen

• For high-risk patients, a typical bridging regimen may include stopping warfarin 5 days before the procedure, starting low-molecular-weight heparin when INR falls below 2.0, stopping low-molecular-weight heparin 24 hours before the procedure, and resuming both medications afterward.
• However, the specific bridging regimen should be tailored to the individual patient's risk factors and the procedure they're undergoing, with careful consideration of bleeding risk and thrombotic risk 1.

From the Research

Bridging Therapy for Anticoagulant

• The effectiveness of bridging therapy for anticoagulant patients has been studied in various research papers 2, 3, 4.
• According to a study published in 2020, periprocedural bridging with heparin for warfarin-treated patients reveals a consistent two- to three-fold increase in the risk of major bleeding and no benefit in terms of a reduction in the risk of stroke and systemic embolism 2.
• Another study from 2007 recommends starting warfarin with unfractionated heparin or low-molecular-weight heparin for at least five days and continuing until a therapeutic International Normalized Ratio (INR) is achieved 3.
• A 2010 study suggests that low-molecular-weight heparin is the preferred agent over intravenous unfractionated heparin for bridging therapy, including patients with prosthetic heart valve indications for vitamin K antagonist therapy 4.
• The risk of thrombosis exceeds the risk of bleeding in patients with heparin-induced thrombocytopenia despite an elevated INR > 4, according to a 2005 study 5.
• Monitoring warfarin therapy using the International Normalized Ratio (INR) instead of the prothrombin time ratio can reduce bleeding complications while maintaining an acceptable rate of thromboembolic events, as shown in a 1995 study 6.

Key Findings

• Bridging therapy with heparin may increase the risk of major bleeding without reducing the risk of stroke and systemic embolism 2.
• The choice of bridging therapy should be based on the patient's and procedure's thromboembolic and bleeding risks 3, 4.
• Low-molecular-weight heparin is preferred over intravenous unfractionated heparin for bridging therapy 4.
• The risk of thrombosis exceeds the risk of bleeding in patients with heparin-induced thrombocytopenia despite an elevated INR > 4 5.
• Using the INR to monitor warfarin therapy can reduce bleeding complications 6.