What are the 2017 recommendations on the use of bridging therapy – should it be routinely used or not?
James Douketis: For decades, heparin bridging was used in patients who were on a vitamin K antagonist and needed to stop the antagonist because of a surgery or procedure. Their anticoagulation level went down and then gradually went up, and then, during that middle period, when the levels were subtherapeutic, patients were given bridging therapy with a short-acting heparin. It was typically a low-molecular-weight heparin. Until recently, a lot of patients received that.
In 2015, the BRIDGE (Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery) trial published in the New England Journal of Medicine showed that in patients with atrial fibrillation who were on warfarin and required a surgery or procedure, the use of bridging therapy did not provide any therapeutic advantage. It did not reduce the risk of stroke or thromboembolism. What it did do, however, was increase patients’ risk for major bleeding by about 3 times. Of course, this is something that we want to avoid because it might mean that those patients have to go off their anticoagulant for longer.
For most patients with atrial fibrillation, I do not think there is a need for heparin bridging during the interruption of warfarin. If they are on a newer direct oral anticoagulant (DOAC) – because these drugs have a rapid offset and a rapid onset of action – there really is no role for bridging therapy. There does remain a role for bridging therapy in patients with mechanical heart valves, especially those in the mitral position, and older aortic valves in which there are no good data or trials to support the practice of not bridging.
Finally, there may be a role in patients who have had a recent venous thromboembolism within the last 3 months to prevent disease recurrence, but those cases do not happen very often. Overall, we are moving away from heparin bridging in warfarin, in vitamin K-treated patients, and I do not think there is a role for it in patients on the newer DOAC agents.