Joachim Ehrlich discusses the BRIDGE study and its findings, and how they will be applicable to patients taking new oral anticoagulants rather than warfarin.
Disclosures: Joachim Ehrlich has participated in speakers' bureau for Bayer, Boehringer, BMS, Pfizer and Daichi Sankyo.
FILMED AT THE CARDIOSTIM ANNUAL MEETING, JUNE 2016
WHAT DO CURRENT GUIDELINES RECOMMEND FOR THE NEED FOR BRIDGING ANTICOAGULATION DURING INTERRUPTION OF WARFARIN THERAPY?
00:12 – So the European Society of Cardiology guidelines from 2010, they rather discourage using bridging for interruption of warfarin therapy in patients with atrial fibrillation. This may appear a little bit astounding but in fact, this has been reported to raise the number of bleeding complications rather than adding additional protection from thromboembolic events in these patients. Bridging therapy with low molecular weight heparin or heparin, is recommended in patients at high risk of a stroke, like mechanical valve patients, or patients with a prior stroke. But in the general AF population, it is rather discouraged.
COULD YOU TELL US SOMETHING ABOUT THE BRIDGE STUDY AND ITS FINDINGS?
01:03 – The BRIDGE trial was a prospectively randomised study conducted in patients with oral anticoagulation and atrial fibrillation. These were mostly men, 1,800 mostly hypertensive men, typical atrial fibrillation population, and that trial was prospectively designed a randomised placebo control trial to study if no bridging was not in theory to bridging strategy in atrial fibrillation patients. Patients undergoing a surgical or intervention procedure were randomised to either receive dalteparin, a weight adapted manner, or placebo, and were taken off warfarin five days before the procedure. Then the bridging therapy was started, initiated, and it was restarted after the procedure, and warfarin therapy was also restarted at the evening of the procedure or the next morning. And the results of that trial showed that in terms of stroke and thromboembolic events, there was indeed non-inferiority of non-bridging strategy. But in terms of bleeding, there was significantly less bleeding in the placebo-treated arm compared to the heparin-treated arm.
WILL THESE FINDINGS BE APPLICABLE TO PATIENTS TAKING NEW ORAL ANTICOAGULANTS RATHER THAN WARFARIN?
02:25 – The possibility to transfer the BRIDGE study results to patients with NOACs is a difficult one. Generally, we’ve seen signals that the rate of thromboembolic events and complications goes up with interruption. And that was also documented at the end of the ROCKET AF study with rivaroxaban to prevent thromboembolic events in patients with atrial fibrillation. So there are indications that potentially this might be applicable too. Intuitively one would definitely say so, but data, prospective randomised and controlled data are lacking. There is a small sub study by RELY, an analysis of the RELY trial that looked into dabigatran patients and surgical interventions. This was a pre-specified study and it produced similar results than the BRIDGE study in that there was no difference in the rate of thromboembolic events, but a higher bleeding rate in patients receiving dabigatran and bridging therapy compared to those without bridging therapy.