Hi, I think the most important few words in all this controversy are in the E-mail you read out, which were:

Unless there is a recent embolic event then 'almost all' patients can be off Warfarin for 3 to 4 days.

 

This comment alone is the most important and should be emphasised as being so  to all who discuss this topic. Patients with Hyperthrombotic disorders and coagulation disorders have 'nearly all' had a prior embolic event. I think there is a danger from Jim using the term 'almost all' and not quantifying that or even explaining it fully.

 

On the subject of quantification I have used the term 'nearly all' to show that the vague terms can be used to explain or justify any statement, but without numbers the initial statement is useless.

 I represent a group of patients who are at risk of clotting events when Warfarin is removed and as an example of the danger of removal of Warfarin I would cite the paper:

Catastrophic cerebral antiphospholipid syndrome presenting as cerebral infarction with haemorrhagic transformation after sudden withdrawal of warfarin in a patient with primary antiphospholipid syndrome

Authored by: Abdul Majid Wani, Waleed Mohd Hussain, Mousa Ali Al Mejally, Khaled Shawkat Ali, Sadeya Hanif Raja, Wael Al Maimani, Mazen G Bafaraj, Ashraf Bashraheel, Mubeena Akhtar, Amer Mohd Khoujah

Summary:

Catastrophic antiphospholipid syndrome (APS) is caused by thrombotic vascular occlusions that affect both small and large vessels, producing ischaemia in the affected organs. The “catastrophic” variant of the antiphospholipid syndrome (cAPS) develops over a short period of time. Although patients with cAPS represent <1% of all patients with APS, they are usually life threatening with a 50% mortality rate. A strong association with concomitant infection is thought to act as the main trigger of microthromboses in cAPS. Several theories have been proposed to explain these physiopathological features. Some of them suggest the possibility of molecular mimicry between components of infectious microorganisms and natural anticoagulants, which might be involved in the production of cross-reacting antiphospholipid antibodies. We present a case of catastrophic cerebral APS characterised by massive temporal lobe infarction and subsequent haemorrhagic transformation after sudden withdrawal of warfarin.

The whole debate will run on for many years to come until an alternative anticoagulant is found but the increased risk of clotting events following Warfarin discontinuation are too great for many patients to even contemplate, so much of the discussion is irrellevant and purely acedemic as the patients needs should come first, above costs and the nuisance factor of bridging.

The Bridge Study will certainly be useful in determining if "bridging" a-fib patients is beneficial or not.  Currently, my facility does not routinely bridge this patient population.  What I would be more interested in is a study involving the patient population with a history of DVT/PE.  I think we all agree that a recent DVT/PE needs to be bridged, but what about those patients with a DVT/PE 1.5 years earlier?  To me, those are the questionable patients and unfortunately the Bridge Study will only be addressing the a-fib population and these results will not be applicable to any other patient population.

 Sean Burroughs PharmD

What about bridging to warfarin POST-OP. Does the same criteria apply.