Abstract:
Anticoagulants are commonly used drugs that are frequently encountered during device placement. Deciding when to halt or continue the use of anticoagulants is a balance between the risks of thromboembolism versus bleeding. Patients taking warfarin with a high risk of thromboembolism should continue to take their warfarin without interruption during device placement while ensuring their international normalized ratio remains below 3. For patients who are taking warfarin and have low risk of thromboembolism, either interrupted or continued warfarin may be used, with no evidence to clearly support either strategy. There is little evidence to support continuing direct acting oral anticoagulants (DOACs) for device implantation. The timing of halting these medications depends largely on renal function. If bleeding occurs, warfarin?s anticoagulation effect is reversible with vitamin K and activated prothrombin complex concentrate. There are no DOAC reversal agents currently available, but some are under development. Regarding antiplatelet agents, aspirin alone can be safely continued while clopidogrel alone may also be continued, but with a slightly higher bleeding risk. Dual antiplatelet therapy for bare-metal stent/drug-eluting stent implanted within 4 weeks/6 months, respectively, should be continued due to high risk of stent thrombosis; however, if they are implanted after this period, then clopidogrel can be halted 5 days before the procedure and resumed soon after, while aspirin is continued. If the patient is taking both aspirin and warfarin, aspirin should be halted 5 days prior to the procedure, while warfarin is continued.
Keywords
Anticoagulant; Antiplatelet; Cardiac implantable device surgery
Citation: Ahmed AlTurki, Riccardo Proietti, David H. Birnie, Vidal Essebag Management Of Antithrombotic Therapy During Cardiac Implantable Device Surgery http://dx.doi.org/10.1016/j.joa.2015.12.003
Received: 22 October 2015, Revised: 3 December 2015, Accepted: 8 December 2015, Available online: 18 January 2016
Copyright: © 2015 Japanese Heart Rhythm Society. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Conclusion
Antithrombotic therapy and its peri-procedural management continue to be a rapidly evolving area. There is now clear evidence that continuing warfarin treatment during CIED surgery insertion is safe, without a significant increased rate of bleeding and with continued prevention of thromboembolism. For patients at high thromboembolic risk, continued warfarin therapy should be favored over heparin bridging, which increases bleeding, device pocket hematoma, and health care costs. Presently, the use of DOACs is commonly halted prior to insertion, but new evidence is eagerly awaited to evaluate the risk to benefit ratio of their continuation peri-operatively. The predictability and speed of their waning effect is an advantage and the forthcoming availability of specific- and complete-reversal agents may relieve concerns about the management of potential bleeding complications. Combination antithrombotic therapy at the time of CIED should be avoided when possible (e.g. in the absence of recent stent), with temporary interruption of antiplatelet agents for patients on continued OAC.
Funding
Dr. Essebag is the recipient of a Clinician Scientist award from the Canadian Institutes of Health Research (CIHR).
Conflict of interest
All authors declare no conflict of interest related to this study.
