Bridging anticoagulation therapy

Oral anticoagulation therapy is used in patients with various diagnoses to reduce the risk of thromboembolic events or to induce a hypocoagulation state to facilitate dissolution of a thrombus. In clinical practice we often encounter anticoagulated patients, many of whom have been diagnosed with nonvalvular atrial fibrillation. Each year a significant number of these patients undergo a medical procedure, which, in some cases, requires temporary discontinuation of anticoagulation therapy. However without anticoagulation therapy, the patient is at increased risk of thromboembolic events. Therefore, parenteral anticoagulants with fast onset and rapid cessation of action can be used to reduce risk while patients are without adequate oral anticoagulation. Here we summarized the currently available data, which has been drawn from guidelines and other expert documents of European Society of Cardiology (ESC), American College of Cardiology (ACC) and American College of Chest Physicians (CHEST). The vast majority of available studies, including the only single randomized, double-blind, placebo-controlled BRIDGE trial, report an increased risk of major bleeding in patients on bridging therapy. A subanalysis of the RE-LY trial, also found that thromboembolic risk in patients with bridging therapy was significantly higher. The most detailed recommendation for use of bridging therapy in patients with nonvalvular atrial fibrillation was provided by the 2017 Expert Consensus of the ACC, while the ESC only marginally discusses bridging therapy in their expert documents. Bridging is not generally necessary in patients taking non-vitamin K oral anticoagulants (NOACs), but if clinical circumstances require it, the risks and benefits are the same as with vitamin K antagonist (VKA) anticoagulation. Data on the use of NOACs for bridging therapy are scarce.