Key result
Peri-procedural warfarin bridging is linked to ~2-fold higher bleeding without reducing thromboembolic events.
Why the study?
The 2023 AHA/ACC/HRS guidelines recommend against peri-procedural warfarin bridging in AF patients based solely on CHA₂DS₂-VASc score without additional thromboembolic risk factors. This study sought to evaluate adherence to institutional peri-procedural guidelines incorporating patient-specific factors and associated thromboembolic and bleeding events in moderate-to-high risk AF patients.
Does peri-procedural warfarin bridging affect 30-day thromboembolic and bleeding events compared to non-bridging in patients with atrial fibrillation at moderate-to-high thromboembolic risk?
Observational (n=145)
No
Does peri-procedural warfarin bridging affect 30-day thromboembolic and bleeding events compared to non-bridging in patients with atrial fibrillation at moderate-to-high thromboembolic risk?
Absolute Event Rate: 18.4% vs 8.6%
In AF patients at moderate-to-high thromboembolic risk undergoing procedures, omitting warfarin bridging showed a trend toward fewer bleeding events without increasing thromboembolic events, amid high adherence to institutional guidelines.
Supports forgoing bridging to reduce bleeding in selected patients; leaves open need for randomized confirmation of thromboembolic safety.
Background: The 2023 AHA/ACC/HRS guidelines recommend against peri-procedural bridging of warfarin in patients with atrial fibrillation (AF) based solely on CHA₂DS₂-VASc score without additional thromboembolic (TE) risk factors. At our institution, decisions regarding bridging in moderate-to-high TE risk AF patients who require anticoagulation interruption incorporate patient-specific factors. Objective: To evaluate adherence to institutional peri-procedural guidelines and associated TE and bleeding events. Methods: This retrospective, single-center, observational study included AF patients receiving warfarin for stroke prevention enrolled in the anticoagulation management service. Patients had moderate-to-high TE risk (CHA₂DS₂-VASc ≥5 or other TE risk factors) and underwent moderate-to-high bleeding risk procedures between August 2023 and August 2024. Major outcomes included a composite of TE events (deep vein thrombosis, pulmonary embolism, cerebrovascular accidents, or transient ischemic attack) and a composite of International Society on Thrombosis and Haemostasis (ISTH) major and clinically relevant non-major bleeding (CRNMB) events within 30 days post-procedure. Minor outcomes included individual components of the composite outcomes and adherence to the institutional guideline. Results: Of the 145 procedures, bridging therapy was used in 87 (60%) and omitted in 58 (40%), with 92.4% compliance to institutional guidance. No TE events were observed. Of 21 bleeding events, one ISTH major bleed occurred in the bridging group and was attributed to the procedure, while 20 were CRNMB events. There were 15 (17.4%) CRNMB events in the bridging group and 5 (8.6%) in the non-bridging group. Conclusion: High adherence to institutional bridging guidelines was observed. A trend towards fewer bleeding events with no increased TE events was found in the non-bridging group in patients with moderate-to-high TE risk.
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Sinan et al. (2026) conducted an observational in Atrial fibrillation (n=145). Peri-procedural warfarin bridging therapy vs. Omission of peri-procedural bridging therapy was evaluated on Composite of thromboembolic events (DVT, PE, CVA, or TIA) and composite of ISTH major and clinically relevant non-major bleeding (CRNMB) events within 30 days post-procedure. Peri-procedural warfarin bridging had 92.4% guideline adherence, 0% thromboembolic events in both arms, and higher CRNMB rates vs non-bridging (17.4% vs 8.6%).
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