When to use bridging therapy? Do we need it for novel oral anticoagulants?
James Douketis: Bridging anticoagulation has been used for a number of years for patients who are on anticoagulants like warfarin during the time that they are having surgery, before, and after to minimalize the time they are not anticoagulated when they are taken off their warfarin and when the warfarin is resumed. One important trial, the BRIDGE trial, showed us that we probably do not need to bridge most patients with atrial fibrillation who are on warfarin and require temporary treatment interruption for an elective surgical procedure, because without bridging there is no difference in the outcome of arterial thromboembolism, but with bridging there were more major bleeds. So, no advantage in terms of reducing thromboembolism and disadvantage with increasing bleeding when using bridging.
Having said that, there are still some patients whom we would continue to bridge. I would suggest, when that is the case, to use the protocol that was developed in the BRIDGE trial, because it is easy to use and relatively safe and effective. Who are these patients? Patients with mechanical mitral valves, most patients with mechanical aortic valves, and then some patients who have had thromboembolic complications in the past during temporary interruption of their anticoagulants around the time of surgery.