In patients with atrial fibrillation (AFib), does withholding bridging anticoagulation increase the incidence of postoperative stroke?

From the Guidelines

In patients with atrial fibrillation who do not receive bridging anticoagulation, there is generally not a higher incidence of post-operative stroke compared to those who do receive bridging. The current evidence suggests that for most patients with atrial fibrillation, interrupting warfarin or direct oral anticoagulants (DOACs) without bridging is the preferred approach for most surgeries, as it provides the best balance between preventing thromboembolism and avoiding excessive bleeding complications 1. Some key points to consider include:

• Bridging therapy with heparin or low molecular weight heparin is typically reserved only for patients at the highest risk of thromboembolism, such as those with mechanical heart valves, recent stroke/TIA within 3 months, or very high CHADS2 scores (5-6) 1.
• For most atrial fibrillation patients with moderate risk, simply stopping the oral anticoagulant before surgery (typically 2-3 days for warfarin, 24-48 hours for DOACs depending on renal function and bleeding risk of the procedure) and resuming it after surgery when hemostasis is adequate is a suitable approach 1.
• The temporary hypercoagulable state induced by surgery appears to be balanced by the residual anticoagulant effect during brief interruptions, which supports the decision to avoid bridging in most cases 1.
• The BRIDGE trial and other studies have shown that bridging therapy significantly increases bleeding risk without providing substantial reduction in stroke risk for most atrial fibrillation patients 1. Overall, the decision to use bridging anticoagulation should be individualized based on the patient's specific risk factors and the type of surgery being performed, with a focus on minimizing the risk of both thromboembolism and bleeding complications 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Incidence of Post-Op Stroke in Patients with Atrial Fibrillation

• The incidence of post-op stroke in patients with atrial fibrillation who do not receive bridging anticoagulation is a topic of interest in several studies 2, 3, 4, 5, 6.
• A study published in The New England Journal of Medicine in 2015 found that forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism, with a risk difference of 0.1 percentage points (95% CI, -0.6 to 0.8; P=0.01 for noninferiority) 2.
• Another study published in the Journal of Stroke and Cerebrovascular Diseases in 2016 found that the no bridging group did not have any significant difference in mortality or cerebrovascular accidents compared to the heparin bridging group, but had significantly less major bleeding (OR, 0.41; 95% CI, 0.24-0.68; P=0.0006) 3.
• A microsimulation analysis published in the Journal of General Internal Medicine in 2017 found that the benefits and harms of bridging anticoagulation vary according to underlying patient risk profiles for both thromboembolic stroke and major intracranial bleeding 4.
• A study published in the Journal of Thrombosis and Thrombolysis in 2010 found that bridging with low molecular weight heparin was associated with lower risks of VTE and death within 30 days of discharge, but not with lower stroke or greater bleeding risk 5.
• A prospective study published in Circulation in 2006 found that low-molecular-weight heparin as a bridging anticoagulant early after mechanical heart valve replacement was feasible, with a low incidence of bleeding and thromboembolic events 6.

Risk of Stroke and Bleeding

• The risk of stroke and bleeding in patients with atrial fibrillation who do not receive bridging anticoagulation is influenced by various factors, including the patient's underlying risk profile and the type of anticoagulant used 2, 3, 4.
• The CHADS2 score, which assesses the risk of stroke in patients with atrial fibrillation, is an important factor in determining the need for bridging anticoagulation 3, 4, 5.
• The risk of bleeding is also an important consideration, and studies have shown that bridging anticoagulation can increase the risk of major bleeding 2, 3, 5.