"Bridging” is a term that refers to the use of short-acting anticoagulants (heparin or LMWH) for a period of time during the interruption of warfarin therapy when the INR is not within a therapeutic range.

There is no established single bridging regimen.  Variability exists in the type of anticoagulant, the intensity of anticoagulation and the timing of perioperative administration. In considering which regimen and administration approach to use, there are several points to consider:

  • Anticoagulant intensity to prevent thromboembolism
  • Proximity ot surgery of anticoagulant administration and risk for bleeding
  • Dose of anticoagulant administration and risk for bleeding

General recommendations:

  1. Stop therapeutic LMWH at least 24 hours prior to surgery
  2. Stop prophylactic LMWH at least 12 hours prior to surgery
  3. Resume LMWH once normal hemostasis is achieved (usually ~24-48 hours later) or based on thromboembolic risk (often evening of THA or TKA)

See “Peri-Procedural Anticoagulation Recommendations” for more information.


Perioperative Management of Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141;e326S-e350S