A Bridge to Nowhere? Benefits and Risks for Periprocedural Anticoagulation in Atrial Fibrillation.

In patients with atrial fibrillation (AF), oral anticoagulation is used to prevent stroke and systemic embolism. In a common clinical scenario, AF patients frequently undergo invasive procedures requiring temporary interruption of oral anticoagulation, thereby potentially exposing such patients to increased risk of thromboembolism. Bridging anticoagulation has been used clinically to mitigate this perceived thromboembolic risk, though this practice may also increase risk of periprocedural bleeding. High-quality data has not previously existed to inform decision-making in this clinical situation of bridging anticoagulation. We discuss recent results from the BRIDGE trial and secondary analyses from recent phase 3 randomized clinical trials of direct-acting oral anticoagulant (DOAC) use in non-valvular AF, that inform periprocedural anticoagulation with bridging strategies in AF patients. Updated data from these current trials favor against a strategy of bridging anticoagulation for elective procedures in the majority of AF patients, low or moderate in thromboembolic risk. Bridging anticoagulation is associated with an increased risk of bleeding and no decreased risk of thromboembolism.