title: Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation.
abstract: BACKGROUND
  It is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding.
  
  
  METHODS
  We performed a randomized, double-blind, placebo-controlled trial in which, after perioperative interruption of warfarin therapy, patients were randomly assigned to receive bridging anticoagulation therapy with low-molecular-weight heparin (100 IU of dalteparin per kilogram of body weight) or matching placebo administered subcutaneously twice daily, from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. Warfarin treatment was stopped 5 days before the procedure and was resumed within 24 hours after the procedure. Follow-up of patients continued for 30 days after the procedure. The primary outcomes were arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding.
  
  
  RESULTS
  In total, 1884 patients were enrolled, with 950 assigned to receive no bridging therapy and 934 assigned to receive bridging therapy. The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (risk difference, 0.1 percentage points; 95% confidence interval [CI], -0.6 to 0.8; P=0.01 for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority).
  
  
  CONCLUSIONS
  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. (Funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health; BRIDGE ClinicalTrials.gov number, NCT00786474.).
authors.affiliation: From St. Joseph's Healthcare Hamilton (J.D.D.) and the Department of Medicine (J.D.D.) and Hamilton Health Science Center (S.S., A.G.G.T.), McMaster University, Hamilton, ON, Canada; Hofstra North Shore-Long Island Jewish School of Medicine, Manhasset (A.C.S.), and Mount Sinai Medical Center, New York (A.S.D.) - both in New York; Hurley Medical Center, Flint, MI (S.K.); University of Cincinnati College of Medicine, Cincinnati (R.C.B.); NorthShore University HealthSystem, Evanston (J.A.C.), and Rush University Medical Center, Chicago (A.K.J.) - both in Illinois; University of Washington Medical Center, Seattle (D.A.G.); Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA (A.J.); and Duke Clinical Research Institute (D.F.K., V.H.) and Department of Medicine (T.L.O.), Duke University Medical Center, Durham, NC.
authors.forename: James D
authors.initials: JD
authors.lastname: Douketis
authors.forename: Alex C
authors.initials: AC
authors.lastname: Spyropoulos
authors.forename: Scott
authors.initials: S
authors.lastname: Kaatz
authors.forename: Richard C
authors.initials: RC
authors.lastname: Becker
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Caprini
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Dunn
authors.forename: David A
authors.initials: DA
authors.lastname: Garcia
authors.forename: Alan
authors.initials: A
authors.lastname: Jacobson
authors.forename: Amir K
authors.initials: AK
authors.lastname: Jaffer
authors.forename: David F
authors.initials: DF
authors.lastname: Kong
authors.forename: Sam
authors.initials: S
authors.lastname: Schulman
authors.forename: Alexander G G
authors.initials: AG
authors.lastname: Turpie
authors.forename: Vic
authors.initials: V
authors.lastname: Hasselblad
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Ortel
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000188:drug therapy*; D004311:Double-Blind Method; D017558:Elective Surgical Procedures; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D008297:Male; D059035:Perioperative Period; D011183:Postoperative Complications / Q000517:prevention & control; D013923:Thromboembolism / Q000517:prevention & control*; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D014859:Warfarin