WHAT’S NEW
High-quality evidence suggests it’s OK to stop warfarin before surgery
This is the largest good-quality study to evaluate perioperative bridging in patients with atrial fibrillation who were at low or moderate risk for ATE (CHADS2 score, 0-4). Previous studies suggested bridging increased bleeding and offered limited benefit for reducing the risk for ATE. However, this is the first study to include a large group of moderate-risk patients (CHADS2 score, 3-4). This trial provides high-quality evidence to support the practice of simply stopping warfarin in the perioperative period, rather than bridging with LMWH.
CAVEATS
Findings might not apply to patients at highest risk
Most patients in this study had a CHADS2 score ≤ 3. About 3% had a CHADS2 score ≥ 5. It’s not clear whether these findings apply to patients with a CHADS2 score of 5 or 6.
This trial categorized ATE risk using the CHADS2 score, rather than the CHA2DS2-VASc, which includes additional risk factors and may more accurately predict stroke risk. Both patients who received bridging therapy and those who did not had a lower rate of stroke than predicted by CHADS2. This may reflect a limit of the predictive value of CHADS2 but should not have affected the rate of bleeding or ATE outcomes in this study.
Continue for challenges to implementation >>