Abstract
A substantial proportion of patients who undergo cardiac device implantation receive oral anticoagulation to prevent thromboembolism or antiplatelets to prevent thrombotic events. Anticoagulation and antiplatelets increase the risk of hemorrhagic complications, while discontinuation may increase thromboembolic risk and thrombotic events. With the introduction of non-vitamin K antagonist oral anticoagulant agents and the newer antiplatelet agents such as prasugrel or ticagrelor, the perioperative management of patients has become more challenging. In this article, we review the recent trials and meta-analysis and describe the available evidence, as well as the current recommendations in order to inform best practice. We also reinforce the importance of further trials in this complex and rapidly evolving area.
Papers of special note have been highlighted as: • of interest; •• of considerable interest
References
- 1 . The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: calendar year 2009 a World Society of Arrhythmia's project. Pacing Clin. Electrophysiol. 34(8), 1013–1027 (2011).
- 2 A comparison of single-lead atrial pacing with dual-chamber pacing in sick sinus syndrome. Eur. Heart J. 32(6), 686–696 (2011).
- 3 Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N. Engl. J. Med. 352(3), 225–237 (2005).
- 4 The European cardiac resynchronization therapy survey: comparison of outcomes between de novo cardiac resynchronization therapy implantations and upgrades. Eur. J. Heart Fail. 13(9), 974–983 (2011).
- 5 . Managing anticoagulation in patients receiving implantable cardiac devices. Future Cardiol. 8(3), 393–411 (2012).
- 6 Antithrombotic management in patients undergoing electrophysiological procedures: a European Heart Rhythm Association (EHRA) position document endorsed by the ESC Working Group Thrombosis, Heart Rhythm Society (HRS), and Asia Pacific Heart Rhythm Society (APHRS). Europace 17(8), 1197–1214 (2015). • European Heart Rhythm Association consensus recommendations about antithrombotic management in patients undergoing cardiac devices implantation.
- 7 Management of antithrombotic therapy in patients undergoing electrophysiological device surgery. Europace 17(6), 840–854 (2015). • Practical recommendations for the management of antithrombotic therapy in patients undergoing cardiac implantable electronic device surgery.
- 8 The frequency and incremental cost of major complications among medicare beneficiaries receiving implantable cardioverter-defibrillators. J. Am. Coll. Cardiol. 47(12), 2493–2497 (2006).
- 9 Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm 2(9), 907–911 (2005).
- 10 Pocket hematoma after pacemaker or implantable cardioverter defibrillator surgery: influence of patient morbidity, operation strategy, and perioperative antiplatelet/anticoagulation therapy. Chest 126(4), 1177–1186 (2004).
- 11 Increased complication rates of cardiac rhythm management devices in ESRD patients. Am. J. Kidney Dis. 49(5), 656–663 (2007).
- 12 Pacemaker or defibrillator surgery without interruption of anticoagulation. N. Engl. J. Med. 368(22), 2084–2093 (2013). •• Large randomized control trial comparing the incidence of device pocket hematoma in patients undergoing cardiac device implantation between continuing warfarin treatment or bridging therapy with heparin.
- 13 Meta-analysis of safety and efficacy of uninterrupted warfarin compared to heparin-based bridging therapy during implantation of cardiac rhythm devices. Am. J. Cardiol. 110(10), 1482–1488 (2012).
- 14 . Meta-analysis of bleeding complications associated with cardiac rhythm device implantation. Circ. Arrhythm. Electrophysiol. 5(3), 468–474 (2012).
- 15 Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry. Circulation 122(16), 1553–1561 (2010).
- 16 Risk factors and time delay associated with cardiac device infections: Leiden device registry. Heart 95(9), 715–720 (2009).
- 17 Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective study. Circulation 116(12), 1349–1355 (2007).
- 18 . Lead perforation: incidence in registries. Pacing Clin. Electrophysiol. 31(1), 13–15 (2008).
- 19 2012 focused update of the ESC guidelines for the management of atrial fibrillation. Eur. Heart J. 33(21), 2719–2747 (2012).
- 20 . Management of antithrombotic therapy during cardiac implantable device surgery. J. Arrhythm. 32(3), 163–169 (2016). •• Recent review article on management of anithrombotic therapy during cardiac device implantation.
- 21 CHADSVASC. www.chadsvasc.org.
- 22 Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur. J. Anaesthesiol. 27(2), 92–137 (2010).
- 23 . Stroke risk in anticoagulated patients with atrial fibrillation: the Atrial Fibrillation Investigators. Stroke 40(4), 1410–1416 (2009).
- 24 . Decline of protein C and S and factors II, VII, IX, X during the initiation of warfarin therapy. Throm. Res. 45(6), 783–790 (1987).
- 25 . Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation 89(2), 635–641 (1994).
- 26 ESC Guidelines on the management of valvular heart disease (version 2012). Eur. Heart J. 33(19), 2451–2496 (2012).
- 27 . A new scoring system to determine thromboembolic risk after heart valve replacement. Circulation 108(1), 68–74 (2003).
- 28 Safety and efficacy outcomes of oral anticoagulants and antiplatelet drugs in the secondary prevention of venous thromboembolism: systematic review and network meta-analysis. BMJ 347, f5133 (2013).
- 29 . Management of anticoagulation before and after elective surgery. N. Engl. J. Med. 336(21), 1506–1511 (1997).
- 30 Temporal relation between clopidogrel cessation and stent thrombosis after drug-eluting stent implantation. Am. J. Cardiol. 103(6), 801–805 (2009).
- 31 Stent thrombosis after drug-eluting stent implantation: incidence, timing, and relation to discontinuation of clopidogrel therapy over a 4-year period. Eur. Heart J. 30(22), 2714–2721 (2009).
- 32 . Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation 119(12), 1634–1642 (2009).
- 33 Lower risk of stent thrombosis and restenosis with unrestricted use of ‘new-generation’ drug-eluting stents: a report from the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Eur. Heart J. 33(5), 606–613 (2012).
- 34 Safety and efficacy of everolimus- versus sirolimus-eluting stents: a systematic review and meta-analysis of 11 randomized trials. Am. Heart J. 165(2), 241–250 (2013).
- 35 Stent thrombosis with drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. Lancet 379(9824), 1393–1402 (2012).
- 36 Double antiplatelet therapy after drug-eluting stent implantation: risk associated with discontinuation within the first year. J. Am. Coll. Cardiol. 60(15), 1333–1339 (2012).
- 37 Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2year results from a prospective observational study. Lancet 382(9906), 1714–1722 (2013).
- 38 . Antithrombocytic therapy and PCI. Duration of therapy after DCB/stents/scaffolds. Herz 39(7), 819–821 (2014).
- 39 2014 ESC/EACTS Guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur. Heart J. 35(37), 2541–2619 (2014).
- 40 Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2), 326–350 (2012).
- 41 The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133(6), 299–339 (2008).
- 42 Postoperative low-molecular-weight heparin bridging is associated with an increase in wound hematoma following surgery for pacemakers and implantable defibrillators. Pacing Clin. Electrophysiol. 32(3), 378–382 (2009).
- 43 Preparation for pacemaker or implantable cardiac defibrillator implants in patients with high risk of thrombo-embolic events: oral anticoagulation or bridging with intravenous heparin? A prospective randomized trial. Eur. Heart J. 30(15), 1880–1884 (2009).
- 44 Continuation of warfarin during pacemaker or implantable cardioverter-defibrillator implantation: a randomized clinical trial. Heart Rhythm 8(4), 536–540 (2011).
- 45 Meta-analysis of continuous oral anticoagulants versus heparin bridging in patients undergoing CIED surgery: reappraisal after the BRUISE study. Pacing Clin. Electrophysiol. 38(4), 417–423 (2015).
- 46 . The safety and efficacy of antithrombotic therapy in patients undergoing cardiac rhythm device implantation: a meta-analysis. Europace 17(7), 1076–1084 (2015). • Largest meta analysis assessing safety and efficacy of antithrombotic therapy in patients undergoing cardiac device implantation.
- 47 . Periprocedual heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation 126(13), 1630–1639 (2012).
- 48 Risk of pocket haematoma in patients on chronic anticoagulation with warfarin undergoing electrophysiological device implantation: a comparison of different peri-operative management strategies. Eur. Rev. Med. Pharmacol. Sci. 19(8), 1461–1479 (2015).
- 49 . Oral anticoagulation continuation compared with heparin bridging therapy among high risk patients undergoing implantation of cardiac rhythm devices. Thromb. Haemost. 108(6), 1124–1131 (2012).
- 50 Perioperative bridging anticoagulation in patients with atrial fibrillation. N. Engl. J. Med. 373(9), 823–833 (2015).
- 51 Cost effectiveness of continued-warfarin versus heparin-bridging therapy during pacemaker and defibrillator surgery. J. Am. Coll. Cardiol. 65(9), 957–959 (2015).
- 52 . Novel oral anticoagulants: clinical pharmacology, indications and practical considerations. Eur. J. Clin. Pharmacol. 69(9), 1617–1633 (2013).
- 53 Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 17(10), 1467–507 (2015).
- 54 Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the randomized evaluation of long-term anticoagulation therapy (RE-LY) randomized trial. Circulation 126(3), 343–348 (2012). •• Randomized trial comparing the periprocedural bleeding risk of patients treated with dabigatran and warfarin.
- 55 Safety of continuous anticoagulation with dabigatran during implantation of cardiac rhythm devices. Am. J. Cardiol. 111(8), 1165–1168 (2013).
- 56 Cardiovascular implantable electronic device implantation with uninterrupted dabigatran: comparison to uninterrupted warfarin. J. Cardiovasc. Electrophysiol. 24(10), 1125–1129 (2013). • Randomized trial comparing the periprocedural bleeding in patients treated with uninterrupted dabigatran versus interrupted dabigatran versus uninterrupted warfarin.
- 57 Treatment with novel oral anticoagulants in a real-world cohort of patients undergoing cardiac rhythm device implantations. Europace 16(7), 1028–1032 (2014).
- 58 Safety of anticoagulation with uninterrupted warfarin vs. interrupted dabigatran in patients requiring an implantable cardiac device. Cardiovasc. Diagn. Ther. 6(1), 3–9 (2016).
- 59 Managing novel oral anticoagulants in patients with atrial fibrillation undergoing device surgery: Canadian survey. Can. J. Cardiol. 30(2), 231–236 (2014).
- 60 Dual antiplatelet therapy and heparin “bridging” significantly increase the risk of bleeding complications after pacemaker or implantable cardioverter-defibrillator device implantation. J. Am. Coll. Cardiol. 55(21), 2376–2382 (2010).
- 61 . Morbidity associated with three different antiplatelet regimens in patients undergoing implantation of cardiac rhythm management devices. Europace 13(3), 395–401 (2011).
- 62 Influence of oral antiplatelet therapy on hemorrhagic complications of pacemaker implantation. Clin. Res. Cardiol. 102(5), 345–349 (2013).
- 63 . Dual antiplatelet therapy increases pocket hematoma complications in Chinese patients with pacemaker implantation. J. Geriatr. Cardiol. 12(4), 383–387 (2015). •• Prospective study assessing the prevalence of the bleeding complications in pacemaker implanted patients receiving different antiplatelet regimens.
- 64 Bleeding complications after pacemaker or cardioverter-defibrillator implantation in patients receiving dual antiplatelet therapy. Neth. Heart J. 18(5), 230–235 (2010).
- 65 Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur. Heart J. 35(45), 3155–3179 (2014).
- 66 Uninterrupted dabigatran versus warfarin for ablation in Atrial Fibrillation. N. Engl. J. Med. 376(17), 1627–1636 (2017).