Management of Anticoagulation Around Pacemaker and Defibrillator Surgery

Birnie, David H.; Healey, Jeff S.; Essebag, Vidal

doi:10.1161/circulationaha.113.006027

Cited by 27 publications

(25 citation statements)

References 25 publications

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“…In the case of dabigatran, discontinuation is recommended 24 hours before in patients with a CrCl ≥80 mL/min, 36 hours before in those with CrCl 50 to 79 mL/min, and 48 hours before in those with a CrCl <50 mL/min. 160 Survey data from implanting physicians suggest wide variation in practice patterns reflecting the uncertainly over optimal management. 161 However, the majority of physicians discontinue NOAC therapy at the time of implantation (82%).…”

Section: Periprocedural Management Of Patients Who Take Noacsmentioning

confidence: 99%

Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association

Raval¹,

Cigarroa²,

Chung³

et al. 2017

Circulation

224

147

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Non–vitamin K oral anticoagulants (NOACs) are now widely used as alternatives to warfarin for stroke prevention in atrial fibrillation and management of venous thromboembolism. In clinical practice, there is still widespread uncertainty on how to manage patients on NOACs who bleed or who are at risk for bleeding. Clinical trial data related to NOAC reversal for bleeding and perioperative management are sparse, and recommendations are largely derived from expert opinion. Knowledge of time of last ingestion of the NOAC and renal function is critical to managing these patients given that laboratory measurement is challenging because of the lack of commercially available assays in the United States. Idarucizumab is available as an antidote to rapidly reverse the effects of dabigatran. At present, there is no specific antidote available in the United States for the oral factor Xa inhibitors. Prothrombin concentrate may be considered in life-threatening bleeding. Healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input.

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Section: Periprocedural Management Of Patients Who Take Noacsmentioning

confidence: 99%

Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association

Raval¹,

Cigarroa²,

Chung³

et al. 2017

Circulation

224

147

View full text Add to dashboard Cite

show abstract

“…In the five studies that reported major bleeding in patients not in patients with moderate-high risk of thrombosis undergoing pacemaker or cardioverter defibrillator surgery. 115 Other procedures for which data support continuation of oral anticoagulation through the peri-procedural period include cataract surgery and minor dental surgery. 116 117 Expert review of reports of dermatologic surgery suggests that it is also reasonable to continue anticoagulation during minor skin procedures.…”

Section: Patients Taking Vkasmentioning

confidence: 99%

Peri-procedural management of patients taking oral anticoagulants

Daniels

2015

BMJ

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The use of oral anticoagulants is becoming increasingly common. For many years warfarin was the main oral anticoagulant available, but therapeutic options have expanded with the introduction of oral direct thrombin (dabigatran) and factor Xa inhibitors (apixaban, rivaroxaban, and edoxaban). Management of patients taking any oral anticoagulant in the peri-procedural period poses a challenge to medical and surgical providers because of the competing risks of thrombosis and hemorrhage. Bridging therapy has been used to minimize time without anticoagulation when warfarin is interrupted for invasive procedures, but validated strategies based on high quality data are lacking. Existing data suggest that the use of bridging therapy may increase the risk of bleeding for some patients without reducing the risk of thrombosis. Clinical trials are currently under way to answer these questions. Because the half lives and time to anticoagulant activity of newer oral anticoagulants are shorter than for warfarin, bridging therapy is not thought to be necessary with these agents. Peri-procedural management of patients taking these agents is complicated by the lack of demonstrated reversal agents in emergency situations, although specific antidotes are being developed and tested. Existing guidelines for peri-procedural management of patients on oral anticoagulants highlight the importance of individualized patient decision making and suggest strategies to minimize complications. From a patient's perspective, given the uncertainties surrounding optimal management, explicit discussions regarding risks and benefits of treatment options and demonstration of effective communication among medical and surgical providers are essential.

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“…Performing CIED procedures in patients on therapeutic warfarin is supported by the most robust evidence base and is the standard of care, [10][11][12][13]29 but there is limited evidence regarding procedures on continuous NOACs. Although this strategy has limited clinical experience, continuous rivaroxaban was used in 55 patients in ROCKET AF with few adverse consequences and low event rates.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5] Many patients with AF benefit from systemic anticoagulation therapy to reduce the risk of stroke. [6][7][8][9] Warfarin has been studied in patients who undergo cardiac implantable electronic device (CIED) procedures [10][11][12][13] ; however, there are limited data on the use and management of non-vitamin-K oral anticoagulants (NOACs) in patients undergoing CIED procedures.…”

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confidence: 99%