BRIDGE trial (NEJM 2015;373:823) demonstrated ↑ risk of bleeding w/ bridging in pts with AF undergoing invasive procedure requiring interruption of VKA (NB: excluded pts w/ mech. valves, stroke/TIA <12wk, major bleeding <6wk, CrCl <30, Plt <100k)
Bridging VKA w/ UFH or LMWH:
• Stop VKA 5d prior to procedure if therapeutic INR. Start UFH or LMWH when INR <2.
• Stop UFH 4-6h prior to surgery and LMWH 12 or 24hrs prior to surgery (depending on dosing interval).
• Restart UFH/LMWH at 24hrs postop if low postprocedural bleeding risk or 48-72hrs if high risk. D/C when INR >2.
• Resume VKA w/in 24hrs postop if no bleeding complications (will not ↑early bleeding risk because effect takes 24-72hrs).
DOACs: generally no bridging required
• Most can be stopped 24-72h prior to surgery, depending on renal function
• If low bleeding risk, can resume 24hrs after procedure. If high bleeding risk, wait 48-72hrs. If unable to take PO for prolonged period or second procedure is anticipated, start UFH/LMWH at the above time points instead.
#Anticoagulation #Bridging #pharmacology #management #Anticoagulants