What is the bridging therapy for anticoagulation in atrial fibrillation (AFib) with a history of stroke?

From the Guidelines

Bridging therapy with low molecular weight heparin (LMWH) or unfractionated heparin (UFH) is not recommended for patients with atrial fibrillation who have had a stroke, as it may increase the risk of symptomatic intracranial bleeding (ICB) 1. For patients with atrial fibrillation who have had a stroke, the management of anticoagulation therapy is crucial to balance the risk of stroke and bleeding.

Key Considerations

• The 2018 European Heart Rhythm Association practical guide recommends that non-vitamin K antagonist oral anticoagulants (NOACs) may be continued or started one day after a transient ischemic attack (TIA) and exclusion of intracranial bleeding (ICB) by imaging 1.
• For patients with mild stroke, oral anticoagulation may be initiated >3 days after an ischemic stroke, while for patients with moderate stroke, anticoagulation may be started >6-8 days, and in patients with severe stroke at >12-14 days, after excluding secondary hemorrhagic transformation by repeating brain imaging 1.
• The use of aspirin 81-325 mg daily may be considered during the waiting period before anticoagulation is initiated 1.

Recommendations

• For patients with atrial fibrillation who have had a stroke, I recommend delaying anticoagulation for 3-14 days depending on stroke severity to prevent hemorrhagic transformation, and then resuming oral anticoagulation with a NOAC or warfarin, without the need for bridging therapy with LMWH or UFH 1.
• The choice of anticoagulant and the timing of initiation should be individualized based on the patient's risk factors, stroke severity, and renal function 1.
• Regular monitoring of renal function and international normalized ratio (INR) is essential to ensure the safe use of anticoagulation therapy 1.

From the FDA Drug Label

Oral anticoagulation therapy with warfarin is recommended in patients with persistent or paroxysmal AF (PAF) (intermittent AF) at high risk of stroke (i.e., having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age >75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus)

The use of warfarin as a bridging therapy for anticoagulant in atrial fibrillation (AF) with stroke is recommended for patients at high risk of stroke, including those with a history of ischemic stroke. The target INR for warfarin therapy in these patients is 2.0-3.0.

• Key points:
  • Warfarin is recommended for patients with AF at high risk of stroke
  • Target INR is 2.0-3.0
  • Bridging therapy is not explicitly mentioned, but warfarin is recommended for long-term anticoagulation in AF patients at high risk of stroke 2

From the Research

Bridging Therapy for Anticoagulant in Atrial Fibrillation with Stroke

• The use of bridging therapy with heparin or heparinoids before warfarin for initiation of anticoagulation in patients with atrial fibrillation is a matter of debate 3.
• A study compared the safety, efficacy, and tolerability of low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) as a bridging method in patients with recent ischemic stroke due to atrial fibrillation, and found that enoxaparin can be a safe and efficient alternative for UFH as bridging therapy 3.
• Another study found that an initial subcutaneous LMWH was safe and effective in ischemic stroke prevention in patients with acute atrial fibrillation, with no patients in the LMWH group developing ischemic stroke/transient ischemic attack during the first 48 hours, compared to 5 patients in the UFH group 4.

Comparison of Bridging Therapies

• A study found that bridging therapy with full-dose low-molecular-weight heparin was associated with a higher risk of early ischemic recurrence and hemorrhagic transformation compared to non-bridged patients 5.
• In contrast, another study found that LMWH can be used safely and effectively in place of unfractionated heparin for acute treatment at the onset of atrial fibrillation and during early cardioversion 6.

Stroke Prevention Strategies

• Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation, and the use of OAC reduces the risk of stroke and death 7.
• Non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, have emerged as additional options for stroke prevention in patients with atrial fibrillation at high risk of stroke and bleeding 7.