- Question
- Is bridging anticoagulation with low-molecular-weight heparin necessary in patients with atrial fibrillation whose warfarin is interrupted for an elective invasive procedure?
- Design
- Randomized, double-blind, placebo-controlled trial of 1884 patients comparing no bridging with bridging, with 30 days of follow-up after the procedure. The hypotheses were noninferiority for arterial thromboembolism and superiority for major bleeding.
- Population
- Patients with atrial fibrillation on warfarin who needed to interrupt it for an elective operation or other invasive procedure.
- Intervention
- Subcutaneous placebo twice daily (no bridging) from 3 days before until 24 hours before the procedure and then for 5 to 10 days afterward; warfarin was stopped 5 days before and resumed within 24 hours after the procedure.
- Control
- Bridging with subcutaneous dalteparin (100 IU per kg of body weight) twice daily on the same pre- and post-procedure schedule.
- Primary outcome
- Arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding.
- Results
- Arterial thromboembolism occurred in 0.4% without bridging and 0.3% with bridging (risk difference 0.1 percentage points; 95% CI -0.6 to 0.8; P=0.01 for noninferiority). Major bleeding was 1.3% without bridging and 3.2% with bridging (relative risk 0.41; 95% CI 0.20 to 0.78; P=0.005 for superiority).
- Safety
- The main safety finding was that bridging with low-molecular-weight heparin increased major bleeding compared with no bridging.
- Conclusion
- Forgoing bridging was noninferior to low-molecular-weight heparin bridging for preventing arterial thromboembolism and reduced the risk of major bleeding.
- Why it matters
- It showed that routine bridging offers no benefit and causes more bleeding in this setting, changing standard perioperative warfarin management in atrial fibrillation.
Card generated automatically with AI from the abstract of the original publication and the trial registry; every figure was checked against those sources. It may contain errors: verify the data at the source before using it for clinical decisions.
Generated on October 14, 2026