Anticoagulation Bridging in High-Risk Patients

Introduction to Bridging

The American College of Cardiology recommends heparin bridging for patients at high thromboembolic risk when acenocoumarol is stopped before surgery, but most patients do not need bridging 1, 2

High-risk patients requiring bridging include those with mechanical mitral valve, older-generation mechanical aortic valve, bileaflet mechanical aortic valve with additional thromboembolic risk factors, and recent thromboembolism (<3 months) 1, 5, 2
Patients who do not need bridging include those with bileaflet mechanical aortic valve without other risk factors, atrial fibrillation without mechanical valves, venous thromboembolism >3 months ago, and bioprosthetic valves 1, 2, 7

The American College of Cardiology suggests stopping acenocoumarol 5 days before surgery and starting therapeutic-dose low-molecular-weight heparin (LMWH) when INR falls below 2.0, with the last LMWH dose given 24 hours before surgery 7, 5, 8
Postoperative resumption of acenocoumarol and LMWH should be based on bleeding risk, with high-bleeding-risk procedures requiring delayed therapeutic LMWH for 48-72 hours 5, 9

The landmark BRIDGE trial showed that bridging causes more harm than benefit in most patients with atrial fibrillation, with non-inferior rates of arterial thromboembolism and significantly lower bleeding rates in non-bridged patients 2
The strength of evidence for bridging is high for patients with mechanical heart valves or recent thromboembolism, but low for other patient groups 1, 2