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Creta A, Ventrella N, Earley MJ, Finlay M, Sporton S, Maclean E, Kanthasamy V, Lemos Silva Di Nubila BC, Ricciardi D, Calabrese V, Picarelli F, Hunter RJ, Lambiase PD, Schilling RJ, Grigioni F, Monkhouse C, Muthumala A, Moore P, Providencia R, Chow A. DOACs vs Vitamin K Antagonists During Cardiac Rhythm Device Surgery: A Multicenter Propensity-Matched Study. JACC Clin Electrophysiol 2024; 10:121-132. [PMID: 37897463 DOI: 10.1016/j.jacep.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/24/2023] [Accepted: 08/30/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND There is a paucity of data comparing vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs) at the time of cardiac implantable electronic device (CIED) surgery. Furthermore, the best management of DOACs (interruption vs continuation) is yet to be determined. OBJECTIVES This study aimed to compare the incidence of device-related bleeds and thrombotic events based on anticoagulant type (DOAC vs VKA) and regimen (interrupted vs uninterrupted). METHODS This was an observational multicenter study. We included patients on chronic oral anticoagulation undergoing CIED surgery. Patients were matched using propensity scoring. RESULTS We included 1,975 patients (age 73.8 ± 12.4 years). Among 1,326 patients on DOAC, this was interrupted presurgery in 78.2% (n = 1,039) and continued in 21.8% (n = 287). There were 649 patients on continued VKA. The matched population included 861 patients. The rate of any major bleeding was higher with continued DOAC (5.2%) compared to interrupted DOAC (1.7%) and continued VKA (2.1%) (P = 0.03). The rate of perioperative thromboembolism was 1.4% with interrupted DOAC, whereas no thromboembolic events occurred with DOAC or VKA continuation (P = 0.04). The use of dual antiplatelet therapy, DOAC continuation, and male sex were independent predictors of major bleeding on a multivariable analysis. CONCLUSIONS In this large real-world cohort, a continued DOAC strategy was associated with a higher bleeding risk compared to DOAC interruption or VKA continuation in patients undergoing CIED surgery. However, DOAC interruption was associated with increased thromboembolic risk. Concomitant dual antiplatelet therapy should be avoided whenever clinically possible. A bespoke approach is necessary, with a strategy of minimal DOAC interruption likely to represent the best compromise.
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Affiliation(s)
- Antonio Creta
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Health Informatics, University College London, London, United Kingdom.
| | | | - Mark J Earley
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Malcolm Finlay
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Sporton
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Edward Maclean
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | | | - Danilo Ricciardi
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Vito Calabrese
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | | | - Ross J Hunter
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Pier D Lambiase
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | | | | | - Amal Muthumala
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Philip Moore
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Rui Providencia
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Health Informatics, University College London, London, United Kingdom
| | - Anthony Chow
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
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Stewart MH, Morin DP. Management of Perioperative Anticoagulation for Device Implantation. Card Electrophysiol Clin 2018; 10:99-109. [PMID: 29428146 DOI: 10.1016/j.ccep.2017.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Periprocedural management of anticoagulation for cardiac device implantation has evolved over the past 20 years. The traditional paradigm of vitamin K antagonist interruption with heparin bridging has now been shown to be less safe than continuation of vitamin K antagonists at therapeutic levels. Dual antiplatelet therapy during device implantation poses substantial risk but is often necessary. The safest dosing strategy for newer direct oral anticoagulants is still not clear.
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Affiliation(s)
- Merrill H Stewart
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Daniel P Morin
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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Rowley CP, Bernard ML, Brabham WW, Netzler PC, Sidney DS, Cuoco F, Sturdivant JL, Leman RB, Wharton JM, Gold MR. Safety of continuous anticoagulation with dabigatran during implantation of cardiac rhythm devices. Am J Cardiol 2013; 111:1165-8. [PMID: 23360767 DOI: 10.1016/j.amjcard.2012.12.046] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 12/23/2012] [Accepted: 12/23/2012] [Indexed: 10/27/2022]
Abstract
The perioperative bleeding risk associated with therapeutic anticoagulation at cardiac implantable electronic device implantation has previously been demonstrated to vary by the specific anticoagulant used. Although uninterrupted anticoagulation with warfarin appears to be safe, heparin products have been shown to increase the risk of perioperative bleeding. However, the risk associated with cardiac implantable electronic device implantation with anticoagulation using dabigatran, a novel oral direct thrombin inhibitor, is not known. We performed a prospective observational study of patients receiving dabigatran for anticoagulation who underwent cardiac implantable electronic device implantation from June 2011 through May 2012. The study end points included thromboembolic and bleeding complications within 30 days of surgery. Major bleeding complications were defined as bleeding requiring surgical intervention, prolongation of hospitalization, and discontinuation of the anticoagulant or transfusion of blood products within 30 days of surgery. Minor bleeding complications included the development of a hematoma not requiring additional intervention. The thrombotic end points included stroke, transient ischemic attack, myocardial infarction, pulmonary embolism, and deep vein thrombosis. A total of 25 patients were identified for inclusion. During the index hospitalization, no thromboembolic or bleeding complications developed. No major bleeding complications occurred within 30 days of surgery. One minor bleeding event (4%) occurred within 30 days of surgery in 1 patient who was also receiving dual antiplatelet therapy. In conclusion, although no thromboembolic or major bleeding events were observed, additional studies are required to define the optimal antithrombotic management in the perioperative period.
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Boyle NG, Tung R. Perioperative anticoagulation in device implantation: Benefitting the uninterrupted. Thromb Haemost 2013; 109:3-4. [DOI: 10.1160/th12-11-0835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 11/19/2012] [Indexed: 11/05/2022]
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