For Professionals · Decision aid
Periprocedural anticoagulant bridging
The patient-facing stop-date calculator deliberately leaves the bridging question to the team. This answers it. Enter the agent, indication, thromboembolic risk and procedure bleeding risk — and the tool returns a thrombotic-risk tier and a clear bridge-or-not call, each with its rationale and guideline anchor. Nothing is stored.
Common questions
Should atrial fibrillation patients on warfarin be bridged?
For most AF patients, no. The BRIDGE trial (Douketis, NEJM 2015; mean CHA₂DS₂-VASc ~2.3) showed that forgoing bridging was non-inferior for arterial thromboembolism and roughly halved major bleeding compared with low-molecular-weight heparin bridging. Bridging is reserved for the highest-risk subsets — recent stroke/TIA, very high CHA₂DS₂-VASc, or rheumatic mitral stenosis — and individualised.
Do patients on a DOAC need bridging?
No. Apixaban, rivaroxaban, edoxaban and dabigatran have short half-lives, so a timed interruption alone achieves a haemostatic window without the bleeding penalty of heparin bridging. The PAUSE study (Douketis, JAMA Intern Med 2019) validated a standardised interruption schedule based on the agent, creatinine clearance and procedural bleeding risk — with no heparin bridge.
Which mechanical heart valves need periprocedural bridging?
The highest-risk mechanical valves — any mechanical mitral valve, older caged-ball or tilting-disc aortic valves, and any mechanical valve with a recent stroke or TIA — are the classic indications where therapeutic-dose heparin bridging may be reasonable. A modern bileaflet aortic valve with no additional risk factors does not routinely require bridging.
When is LMWH restarted after surgery when bridging is used?
Therapeutic-dose low-molecular-weight heparin is typically resumed about 24 hours after a low-bleeding-risk procedure and delayed to roughly 48–72 hours after a high-bleeding-risk procedure, once haemostasis is secured. Warfarin is usually restarted the evening of surgery, and heparin overlaps until the INR is therapeutic.
When should a DOAC be stopped before surgery?
Under the PAUSE schedule, for a low-bleeding-risk procedure the last dose is about 24 hours before (skip roughly one day); for a high-bleeding-risk procedure about 48 hours before (skip roughly two days). Dabigatran intervals are extended when creatinine clearance is below 50 mL/min because it is renally cleared.
Key sources
- BRIDGE trial — Douketis JD et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med 2015;373:823–833.
- 2017 ACC Expert Consensus Decision Pathway on Periprocedural Management of Anticoagulation in Patients with Nonvalvular Atrial Fibrillation — Doherty JU et al. JACC 2017.
- ACCP / CHEST perioperative management of antithrombotic therapy guidance.
- PAUSE study — Douketis JD et al. Perioperative Management of Patients with AF Receiving a DOAC. JAMA Intern Med 2019 — for DOAC interruption.
General decision support for adult elective surgery — verify against current guideline texts and institutional protocol; the treating team's judgement prevails. This page gives day intervals only and no drug dosing.