Anticoagulation Bridging
BRIDGE trial (NEJM 2015;373:823) ...

Anticoagulation Bridging

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
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