Perioperative Anticoagulation Management in Patients on Chronic Oral Anticoagulant Therapy Undergoing Cardiac Devices Implantation: A Meta‐Analysis

Abstract

The perioperative anticoagulation strategy during cardiac implantable electronic devices (CIEDs) implantation is highly variable without consensus among implanting physicians. A systematic literature search was performed in MEDLINE, EMBASE, and the Cochrane Library to identify clinical trials in patients on chronic oral anticoagulant (OAC) therapy undergoing CIEDs implantation. Bleeding and thromboembolic events were compared among heparin bridging, continued OAC, and interrupted OAC groups. Data were expressed as relative risks (RRs) and 95% confidence intervals (CIs) using random effects model. According to the inclusion criteria, totally 14 studies involving 3,744 patients were identified and included in the study. The heparin bridging group showed a significantly higher risk of bleeding events (relative risk [RR] 3.10, 95% confidence interval [CI], 2.02-4.76, P< 0.00001), especially pocket hematoma (RR 3.58, 95% CI, 2.17-5.91, P < 0.00001), but no significantly lower incidence of thromboembolism (RR 1.16, 95% CI, 0.36-3.67, P = 0.81) compared with OAC continuation group. Meanwhile, both unfractionated heparin-bridged and low-molecular-weight heparin-bridged subgroup exhibited a higher risk of bleeding. There was no significant difference between OAC continuation and OAC interruption group in bleeding (RR 0.90, 95% CI, 0.65-1.24, P = 0.52) and thromboembolic (RR 0.57, 95% CI, 0.16-2.01, P = 0.38) complications. The OAC interruption group had an obviously lower incidence of bleeding in comparison with the heparin bridging group and no statistical significance was observed in thrombus occurrence. Implantation of CIEDs with continuous OAC therapy may offer the best option by combining the lower risk of bleeding with rare thromboembolism compared with heparin bridging and OAC interruption therapy.

Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery

“…This study showed no difference in the incidence of TE events or major bleeding complications between the two groups [23]. Two subsequent metaanalyses have shown findings consistent with those of the BRUISE CONTROL and COMPARE trials, including one that included 3744 patients from 14 studies, and found that, in patients undergoing cardiac device implantation, heparin bridging conferred a significantly higher risk of bleeding than continuation of OAC therapy (hazard ratio 3.1; 95% confidence interval [CI] 2.0-4.8), with no significant reduction in the frequency of TE events [20,22]. Together, and as summarized in Table 3, these findings indicate that there are an increasing number of minor procedure/surgery types that can be safely performed without interruption of VKA therapy.…”

“…There are low-quality to moderate-quality data showing that therapy with VKAs, including warfarin, acenocoumarol, and phenprocoumon, does not require interruption for minor procedures, as shown in Table 2. These include dental procedures (tooth extraction; root canal), skin procedures (biopsy; skin cancer removal), and cataract surgery [20][21][22][23][24][25][26][27]. The 2012 ACCP Antithrombotic Therapy Guidelines give only weak Grade 2C recommendations for continuing VKA therapy in these specific situations involving minor procedures, as they have been associated with a low risk of bleeding [3].…”

Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment: 2017 Appendix on Anticoagulants Including Direct Oral Anticoagulants

“…1,2 However, a casecontrol study, meta-analysis and randomized controlled studies have indicated a significantly increased risk of bleeding in patients undergoing heparin replacement instead of continued warfarin therapy. 21,[25][26][27][28][29][30] When a comparison was made between heparin replacement and continued warfarin treatment in terms of pacemaker implantation and atrial fibrillation ablation, no difference was found in thrombosis development, and continued warfarin treatment resulted in a significantly lower incidence of bleeding. 31,32 The risk of postoperative bleeding following endoscopic procedures during warfarin treatment may be reduced by maintaining the PT-INR at the low end of the therapeutic range on the day prior to or on the day of the procedure.…”

“…The previous guidelines (2012) recommended replacing warfarin with heparin in gastroenterological endoscopic procedures with a high risk of bleeding . However, a case–control study, meta‐analysis and randomized controlled studies have indicated a significantly increased risk of bleeding in patients undergoing heparin replacement instead of continued warfarin therapy . When a comparison was made between heparin replacement and continued warfarin treatment in terms of pacemaker implantation and atrial fibrillation ablation, no difference was found in thrombosis development, and continued warfarin treatment resulted in a significantly lower incidence of bleeding .…”

Association of Uninterrupted Oral Anticoagulation during Cardiac Device Implantation with Pocket Hematoma

“…Compared with uninterrupted vitamin K antagonist therapy, bridging with heparin or LMWH resulted in a higher risk of bleeding events (RR, 3.10; 95% CI, 2.02–4.76; P < .00001) and pocket hematoma (RR, 3.58; 95% CI, 2.17–5.91; P < .00001), with no difference in thromboembolic risk (RR, 1.16; 95% CI, 0.36–3.67; P = .81). 18…”