From the Guidelines
Bridging anticoagulation for atrial fibrillation is generally not recommended for most patients, except those with a very high thromboembolic risk, such as a CHA₂DS₂-VASc score of 4 or higher, recent stroke/TIA (within 3 months), or mechanical heart valves, as the risks of bleeding may outweigh the benefits 1. When bridging is considered necessary, the standard approach uses low molecular weight heparin (LMWH) such as enoxaparin 1 mg/kg twice daily or dalteparin 100 IU/kg twice daily.
- For warfarin, stop 5 days before the procedure and start LMWH when INR falls below 2.0.
- For direct oral anticoagulants (DOACs), stop 24-48 hours before the procedure (longer for renal impairment) and start LMWH 24 hours after the last DOAC dose.
- Resume the oral anticoagulant when hemostasis is adequate post-procedure, typically 24-72 hours after surgery depending on bleeding risk. The decision to bridge should be individualized, taking into account the patient's stroke and bleeding risks, as well as their personal preferences and values 1. It is essential to note that the 2019 focused update of the atrial fibrillation guidelines suggests that bridging anticoagulation may be appropriate only in patients with a very high thromboembolic risk, and that the absence of bridging was found to be noninferior to bridging with low-molecular-weight heparin for prevention of arterial thromboembolism and was found to decrease the risk of bleeding 1.
From the FDA Drug Label
Apixaban tablets are indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required
The indication to bridge for afib is not generally required for patients taking apixaban when stopping the medication 24 to 48 hours prior to an intervention, as stated in the dosage and administration section of the label 2. Bridging anticoagulation is not necessary in most cases.
From the Research
Indications to Bridge for Atrial Fibrillation
The decision to bridge for atrial fibrillation (AF) depends on various factors, including the patient's stroke risk and bleeding risk. Several studies have investigated the use of scoring systems, such as CHADS2, CHA2DS2-VASc, and HAS-BLED, to predict these risks.
Stroke Risk Assessment
- The CHA2DS2-VASc score is widely used to assess stroke risk in patients with AF 3, 4.
- A study found that the CHA2DS2-VASc score had modest discrimination in predicting ischemic stroke, with a C-statistic of 0.67 (0.65-0.69) 3.
- Another study found that the CHA2DS2-VASc score identified patients with a CHADS2 score of 1 who were unlikely to benefit from oral anticoagulant therapy, with an annual incidence of stroke or systemic embolus of 0.9% (95% CI: 0.6-1.3) 4.
Bleeding Risk Assessment
- The HAS-BLED score is used to assess bleeding risk in patients with AF 5, 6.
- A study found that the HAS-BLED score had significant discriminatory performance for predicting clinically relevant bleeding, with an area under the curve (AUC) of 0.60 (p<0.0001) 5.
- Another study found that the HAS-BLED score predicted the excess of intracranial bleeding over ischemic stroke only at very high-risk levels (>4) 6.
Bridging Indications
- Patients with a high CHA2DS2-VASc score (>2) may require bridging anticoagulation to reduce their stroke risk 4.
- Patients with a high HAS-BLED score (>4) may be at increased risk of bleeding and may require careful consideration of bridging anticoagulation 6.
- The presence of malignancy may increase the odds of acute cerebrovascular accident, emphasizing the importance of anticoagulation initiation in patients with cancer 7.