Current Trends in Anticoagulation Bridging for Patients With Chronic Atrial Fibrillation on Warfarin Undergoing Endoscopy

Am J Cardiol. 2018 Jun 15;121(12):1548-1551. doi: 10.1016/j.amjcard.2018.02.043. Epub 2018 Mar 16.


For warfarin-treated patients with atrial fibrillation (AF) at low thromboembolic risk, recent studies have shown harm associated with periprocedural bridging using low-molecular-weight heparin. Clinician surveys have indicated a preference toward excessive bridging, especially among noncardiologists; however, little is known about actual practice patterns in these patients. We performed a retrospective evaluation of bridging in the setting of gastrointestinal endoscopy. We identified 938 patients with AF on warfarin who underwent esophagogastroduodenoscopy or colonoscopy between 2012 and 2016 at a tertiary health center. Urgent, inpatient, or advanced endoscopic procedures were excluded. Clinical variables were abstracted using a predefined data dictionary. Values were expressed as means and compared using a t test or a chi-squared test as appropriate. Three hundred seventy-four patients met criteria for analysis. Twenty-five percent of these patients received bridging therapy, including 11% of patients with CHADS2 scores of 0 to 2 without valvular AF or previous venous thromboembolism. Of the clinical variables assessed, CHADS2, CHA2DS2-VASc, and a history of stroke were the strongest predictors of bridging. Cardiologists were also significantly less likely to prescribe bridging than noncardiology providers (18% vs 30%, p = 0.011); this effect was significant when controlling for CHADS2, CHA2DS2-VASc, or stroke history. In conclusion, patients with AF on warfarin receive excessive low-molecular-weight heparin bridging in the setting of endoscopy; the lower rates of bridging observed among cardiologists suggests a need for their increased involvement in this decision making.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Anticoagulants / therapeutic use*
  • Atrial Fibrillation / complications
  • Atrial Fibrillation / drug therapy*
  • Blood Loss, Surgical / prevention & control*
  • Cardiologists
  • Clinical Decision-Making
  • Colonoscopy / methods
  • Deprescriptions
  • Drug Substitution / trends
  • Endoscopy, Digestive System / methods
  • Female
  • Gastroenterologists
  • Heparin, Low-Molecular-Weight / therapeutic use*
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Physicians, Primary Care
  • Postoperative Hemorrhage / prevention & control*
  • Practice Patterns, Physicians' / trends*
  • Retrospective Studies
  • Stroke / etiology
  • Stroke / prevention & control*
  • Warfarin / therapeutic use*


  • Anticoagulants
  • Heparin, Low-Molecular-Weight
  • Warfarin