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Evevident
Original paper
2015NEJMCardiology

BRIDGE

Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

RCTPeriprocedural anticoagulation

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Overview

In AF patients interrupting warfarin for procedures, forgoing LMWH bridging was noninferior for arterial thromboembolism and reduced major bleeding.

Clinical takeaway

BRIDGE showed that routine perioperative bridging is unnecessary and harmful for many AF patients on warfarin, though very high-risk groups still require individualized decisions.

Key result

No bridging was noninferior for arterial thromboembolism (0.4% vs 0.3%) and roughly halved major bleeding.

Practice impact

Avoid routine LMWH bridging for most AF patients interrupting warfarin for elective procedures.

Evidence

Study design

Randomized, double-blind, placebo-controlled noninferiority trial.

Enrollment

1,884

Follow-up

30 days after the procedure.

Geography

United States, Canada

Clinical question

Is no bridging noninferior to LMWH bridging during temporary warfarin interruption in AF?

Population

  • Patients with atrial fibrillation or flutter on warfarin needing interruption for an elective procedure.

Intervention

No perioperative bridging (placebo) while warfarin was interrupted.

Comparator

Bridging with dalteparin.

Primary outcome

Arterial thromboembolism (efficacy) and major bleeding (safety) at 30 days.

Forgoing bridging was noninferior for arterial thromboembolism and significantly reduced major bleeding in AF patients interrupting warfarin.

Absolute difference (no bridging minus bridging) / 0.1 / CI 95% CI -0.6 to 0.8 percentage points / p=0.01 for noninferiority

Key results

  • Arterial thromboembolism: 0.4% with no bridging vs 0.3% with bridging (difference 0.1 percentage points; noninferiority p=0.01).
  • Major bleeding: 1.3% with no bridging vs 3.2% with bridging; RR 0.41 (95% CI 0.20-0.78; p=0.005).
  • Mean CHADS2 score was 2.3, reflecting mostly moderate stroke risk.

Harms

  • Bridging with LMWH more than doubled the risk of major bleeding.
  • Minor bleeding was also more frequent with bridging.

Clinical Use

When to cite

  • When deciding whether to use perioperative heparin bridging for warfarin-treated patients with nonvalvular atrial fibrillation.

Practice impact

  • Avoid routine LMWH bridging for most AF patients interrupting warfarin for elective procedures.

Applicability

  • Most applicable to patients with atrial fibrillation or flutter on warfarin requiring elective procedure interruption.

Limitations

  • Excluded very-high-thrombotic-risk patients, including those with mechanical heart valves or recent stroke/TIA.
  • Procedure-specific bleeding risk still matters; most procedures were low-to-moderate risk.
  • Applies to warfarin, not DOACs (addressed separately by PAUSE).

Common misinterpretations

  • BRIDGE applies to nonvalvular AF; mechanical valves and recent thromboembolism were excluded and may still warrant bridging.
  • The lesson is that routine bridging adds bleeding without preventing strokes, not that anticoagulation can be stopped casually.

Related evidence

PAUSE - Later Trial

Citation

Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015;373(9):823-833. doi:10.1056/NEJMoa1501035

In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding.