Recent studies such as the BRIDGE trial have demonstrated that there is a net harm associated with LMWH bridging. Consideration for bridging should be reserved for patients who are at high risk for thromboembolism such as:
1. Patients with any thromboembolism during past interruptions of anticoagulation, or while on therapeutic anticoagulation
2. Patients with a cerebrovascular accident or transient ischemic attack in the past 3 months
3. Patients with recent (within 1 month) evidence of mural thrombus or left atrial appendage clot
4. Patients with a mitral mechanical valve
5. Patients with older caged ball or tilting disc mechanical valves
6. Patients with VTE in the past 3 months
7. Patients with VTE and a properly diagnosed hypercoagulable state, including antiphospholipid antibody syndrome,
8. Protein C or Protein S deficiency, or antithrombin3 deficiency.
9. CHADS2 score of 5-6 or CHADS2VASc score of 7-9
Additional guidance is available from the American College of Cardiology at:
American College of Cardiology Periprocedural Guidance
In patients undergoing major orthopedic surgeries who do not require bridging, it is still necessary to consider post-operative VTE prophylaxis, due to the high risk of thromboembolism associated with major orthopedic surgeries, until full dose anticoagulation is cleared by the orthopedic surgeon.
In very high risk patients in whom full dose bridging is deemed necessary, it is recommended risks and benefits be discussed with the proceduralist to determine the best course of action for the patient.
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