In 2011 we reviewed clinical updates and controversies surrounding
anticoagulation bridge therapy in patients with
atrial fibrillation (AF). Since then, options for oral anticoagulation have expanded with the addition of four direct oral
anticoagulant (DOAC) agents available in the United States. Nonetheless,
vitamin K antagonist (VKA)
therapy continues to be the treatment of choice for patients who are poor candidates for a DOAC and for whom
bridge therapy remains a therapeutic dilemma. This literature review identifies evidence and guideline and consensus statements from the last 5 years to provide updated recommendations and insight into
bridge therapy for patients using a VKA for AF. Since our last review, at least four major international guidelines have been updated plus a new consensus document addressing
bridge therapy was released. Prospective trials and one randomized controlled trial have provided guidance for perioperative
bridge therapy. The clinical trial data showed that bridging with
heparin is associated with a significant
bleeding risk compared with not bridging; furthermore, data suggested that actual perioperative thromboembolic risk may be lower than previously estimated. Notably, patients at high risk for
stroke have not been adequately represented. These findings highlight the importance of assessing
thrombosis and
bleeding risk before making bridging decisions.
Thrombosis and
bleeding risk tools have emerged to facilitate this assessment and have been incorporated into guideline recommendations. Results from ongoing trials are expected to provide more guidance on safe and effective perioperative management approaches for patients at high risk for
stroke.