Clinician adherence to peri-procedural warfarin bridging guidelines for patients with atrial fibrillation enrolled in an anticoagulation management service.
Abstract
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.