Juan P. Alzate-Granados, Facultad de Medicina, Departamento de Patología, Universidad Nacional de Colombia, Bogotá, Colombia
Jesús A. Manotas-Berdugo, Facultad de Medicina, Universidad del Sinú, Cartagena, Colombia
Adriana J. Agamez-Utria, Facultad de Medicina, Universidad del Sinú, Cartagena, Colombia
Liliana P. Betts-Sáenz, Facultad de Medicina, Universidad del Sinú, Cartagena, Colombia
Rogelio Arias-Toro, Facultad de Medicina, Universidad del Sinú, Cartagena, Colombia
Deiber Paternina-Flerez, Facultad de Medicina, Universidad del Sinú, Cartagena, Colombia
Oral anticoagulation, particularly with vitamin K antagonists (VKA) and direct oral anticoagulants (DOAC), is essential for the prevention of thromboembolism. However, in patients with atrial fibrillation (AF) requiring major surgery, interruption of anticoagulation presents a clinical dilemma, as it increases thrombotic risk while reducing the risk of perioperative bleeding. It was evaluated perioperative anticoagulation management strategies in patients with atrial fibrillation (AF) undergoing major surgery. For this, a systematic review of randomized controlled trials (RCT) was conducted in adult patients with AF receiving chronic anticoagulation who underwent major surgery. The search was performed in databases such as MEDLINE, EMBASE, and Cochrane. Risk of bias was assessed using the Cochrane RoB 2.0 tool. Eight RCT were included, comprising a total of 13 793 patients. The BRIDGE study (n = 1884) showed that omitting heparin bridging therapy did not increase the risk of thromboembolism (0.4 vs. 0.3%; p = NS), but significantly reduced major bleeding (3.2 vs. 1.3%; p < 0.01). In PERIOP2 (n = 1471), bridging therapy also showed no benefit in high-risk patients (thromboembolism 1.0 vs. 1.2%; p = NS). In BRUISE CONTROL I (n = 681), continuing warfarin in cardiac device surgeries significantly reduced surgical hematomas (3.5 vs. 16.0%; p < 0.001). The evidence suggests that omitting bridging therapy in most AF patients on VKA is safe and reduces hemorrhagic complications. DOAC allow for shorter interruption and earlier resumption without increasing thromboembolic events.
Keywords: Atrial fibrillation. Oral anticoagulants. Perioperative management. Bridging therapy. Major surgery.
