Cost-Effectiveness of Bridging Anticoagulation Among Patients with Nonvalvular Atrial Fibrillation

  • Matthew A. PappasEmail author
  • Geoffrey D. Barnes
  • Sandeep Vijan
Original Research



Bridging anticoagulation is commonly prescribed to patients with atrial fibrillation during initiation and interruption of warfarin. Guidelines recommend bridging patients at high risk of stroke, while a recent randomized trial demonstrated overall harm in a population at comparatively low risk of ischemic stroke. Theory suggests that patients at high risk of stroke and low risk of hemorrhage may benefit from bridging, but data informing patient selection are scant.


To estimate the utility and cost-effectiveness of bridging anticoagulation among patients with nonvalvular atrial fibrillation, stratified by thromboembolic and hemorrhagic risk


Cost-effectiveness analysis with lifelong time horizon, from the perspective of a third-party payer

Main Measures

Quality-adjusted life years (QALYs) per bridged patient; US dollars per QALY gained

Key Results

Unselected patients with nonvalvular atrial fibrillation may be harmed by bridging anticoagulation. Hospital admission for bridging is almost never cost-effective, and generally harmful. Among patients carefully selected by both thromboembolic and hemorrhagic risks, outpatient bridging can be beneficial and cost-effective. Results were sensitive to how effectively heparin products reduce stroke risk.


Outpatient bridging anticoagulation can be beneficial and cost-effective for a subset of patients with nonvalvular atrial fibrillation during interruption or initiation of warfarin. Admission for bridging should be avoided.


Monte Carlo method models, statistical atrial fibrillation thromboembolism anticoagulants 


Compliance with Ethical Standards

Conflict of Interest

Dr. Barnes has received grant funding from NIH/NHLBI (K01HL135392) and Blue Cross-Blue Shield of Michigan, and BMS/Pfizer, as well as consulting fees from BMS/Pfizer, Portola, and Janssen. All remaining authors declare that they do not have conflict of interest.

Supplementary material

11606_2018_4796_MOESM1_ESM.pdf (499 kb)
ESM 1 (PDF 499 kb)


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Matthew A. Pappas
    • 1
    • 2
    Email author
  • Geoffrey D. Barnes
    • 3
  • Sandeep Vijan
    • 4
  1. 1.Center for Value-Based Care Research, Medicine Institute Cleveland ClinicClevelandUSA
  2. 2.Department of Hospital Medicine, Medicine Institute Cleveland ClinicClevelandUSA
  3. 3.Frankel Cardiovascular Center, Department of Internal MedicineUniversity of Michigan Health SystemAnn ArborUSA
  4. 4.Division of General Internal Medicine, Department of Internal MedicineUniversity of Michigan Health SystemAnn ArborUSA

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