Most patients on warfarin do not need bridging anticoagulation. Current guidelines recommend against routine bridging, reserving it only for patients at high thromboembolic risk. [1-2] Here is a practical summary:
Stop warfarin ≥5 days before surgery to allow the INR to normalize (target INR ≤1.5 at time of procedure). [1]
Step 2: Determine if Bridging Is Needed
Assess thromboembolic risk. The ACCP and AHA/ACC guidelines recommend against bridging for most patients, including those with atrial fibrillation and VTE, based on the BRIDGE trial showing no reduction in thromboembolism but a threefold increase in major bleeding with bridging. [1-2]
Bridging may be considered in high-risk patients: [1][3]
Mechanical mitral valve (or any mechanical valve with additional risk factors)
Recent stroke or TIA (<3 months)
Severe thrombophilia (e.g., protein C/S deficiency, antiphospholipid syndrome)
CHA₂DS₂-VASc ≥7 or CHADS₂ 5–6
Step 3: How to Bridge (When Indicated)
Use therapeutic-dose LMWH (e.g., enoxaparin 1 mg/kg BID or dalteparin 100 IU/kg BID): [1]
Preoperative: Start LMWH when INR falls below therapeutic range (typically day −3). Give the last dose 24 hours before surgery (give only the morning dose, i.e., half the daily dose, on the day before). [4-5]
Postoperative: Resume LMWH 24 hours after low-bleeding-risk surgery or 48–72 hours after high-bleeding-risk surgery, once hemostasis is adequate. [4]
If using IV UFH instead, stop it 4–6 hours before surgery and restart ≥24 hours postoperatively. [4-5]
Resume warfarin at the usual dose 12–24 hours after surgery (evening of surgery or next day), assuming adequate hemostasis. [1] A full anticoagulant effect takes 4–8 days, so continue LMWH bridging postoperatively until the INR is ≥2.0.