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BRIDGE Trial No Bridging in AF — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyBRIDGE Trial No Bridging in AFEECC

A 75-year-old man with AF on warfarin has a planned elective knee replacement. His surgeon asks about perioperative anticoagulation management. His CHA₂DS₂-VA is 3. He has no mechanical valve. What is the recommended perioperative strategy?

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Correct answer: D — Stop warfarin 5 days before surgery to allow INR to normalise; bridging with LMWH is generally NOT recommended for AF unless the patient has a mechanical valve or very high thromboembolic risk — the BRIDGE trial showed no benefit of bridging in AF

The BRIDGE trial (2015) randomised AF patients on warfarin undergoing elective surgery to bridging with LMWH vs placebo. Results: no difference in arterial thromboembolism, but bridging INCREASED major bleeding by 3-fold. Based on this, the 2024 ESC AF Guidelines recommend: (1) AF without mechanical valve: no bridging for most patients (including CHA₂DS₂-VA up to 5-6); (2) stop warfarin 5 days before surgery; (3) check INR day before — proceed if ≤1.5; (4) restart warfarin 12-24 hours post-operatively when haemostasis permits. Bridging MAY be considered for: very high-risk patients (recent stroke <3 months, mechanical mitral valve, multiple mechanical valves). For AF patients on DOACs: simply hold the DOAC for 24-48h depending on renal function and bleeding risk — no bridging needed.

Reference: ESC (2024): AF Guidelines; BRIDGE Trial