Safety of Continuous Anticoagulation With Dabigatran During Implantation of Cardiac Rhythm Devices

Rowley, C.P.; Bernard, Michael L.; Brabham, William W.; Netzler, Peter C.; Sidney, D.S.; Cuoco, Frank; Sturdivant, J. Lacy; Leman, Robert B.; Wharton, J. Marcus; Gold, Michael R.

doi:10.1016/j.amjcard.2012.12.046

Cited by 55 publications

(26 citation statements)

References 24 publications

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“…The few available observational data are limited by their small cohort size but have not identified significant risks of bleeding with uninterrupted NOAC therapy. 162,163 When a decision is made to interrupt NOAC therapy for cardiac implantable electronic device implantation, the implanting physician must decide when the NOAC therapy should be restarted. This decision is often influenced by patient characteristics, including risk factors for bleeding and the postimplantation physical examination (eg, hematoma).…”

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 2012, Gold and colleagues conducted a large meta‐analysis across 13 studies in 5978 patients undergoing device implantation while on warfarin, 72% of which were anticoagulated due to AF . Uninterrupted OAC during device implantation did not result in excess bleeding relative to no therapy, whereas patients managed with a heparin‐bridging strategy had over 5‐fold increased bleeding compared to continued OAC . Another meta‐analysis by Ghanbari and colleagues in 2007 demonstrated reduced bleeding risk in patients treated with uninterrupted warfarin relative to heparin bridging, without increased risk of thromboembolic stroke .…”

Section: Discussionmentioning

confidence: 99%

Oral anticoagulation management in patients with atrial fibrillation undergoing cardiac implantable electronic device implantation

Black‐Maier

Kim

Steinberg

et al. 2017

Clinical Cardiology

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BackgroundOral anticoagulation (OAC) therapy is associated with increased periprocedural risks after cardiac implantable electronic device (CIED) implantation. Patterns of anticoagulation management involving non–vitamin K antagonist oral anticoagulants (NOACs) have not been characterized.HypothesisAnticoagulation strategies and outcomes differ by anticoagulant type in patients undergoing CIED implantation.MethodsUsing the nationwide Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we assessed how atrial fibrillation (AF) patients undergoing CIED implantation were cared for and their subsequent outcomes. Outcomes were compared by oral anticoagulant therapy (none, warfarin, or NOAC) as well as by anticoagulation interruption status.ResultsAmong 9129 AF patients, 416 (5%) underwent CIED implantation during a median follow‐up of 30 months (interquartile range, 24–36). Of these, 60 (14%) had implantation on a NOAC. Relative to warfarin therapy, those on a NOAC were younger (70.5 years [range, 65–77.5 years] vs 77 years [range, 70–82 years]), had less valvular heart disease (15.0% vs 31.3%), higher creatinine clearance (67.3 [range, 59.7–99.0] vs 65.8 [range, 50.0–91.6]), were more likely to have persistent AF (26.7% vs 22.9%), and use concomitant aspirin (51.7% vs 35.2%). OAC therapy was commonly interrupted for CIED in 64% (n = 183 of 284) of warfarin patients and 65% (n = 39 of 60) of NOAC patients. Many interrupted patients received intravenous bridging anticoagulation: 33/183 (18%) interrupted warfarin and 4/39 (10%) interrupted NOAC patients. Thirty‐day periprocedure bleeding and stroke adverse events were infrequent.ConclusionsManagement of anticoagulation among AF patients undergoing CIED implantation is highly variable, with OAC being interrupted in more than half of both warfarin‐ and NOAC‐treated patients. Bleeding and stroke events were infrequent in both warfarin and NOAC‐treated patients.

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“…Low bleeding risk procedures can be further divided into general categories wherein anticoagulation could be continued (ie, no interruption of therapy) or interrupted for a relatively short period. 25,26 One must also keep in mind that epidural or spinal (neuraxial) anesthesia possesses a high (or serious) risk for bleeding. 19 In general, before a procedure, a strategy of drug management (including for the NOACs) is necessary to consider whether it is preferable to maintain a low, moderate, or full intensity of anticoagulation according to the concomitant risk for bleeding and thrombosis in the periprocedural period.…”

Section: Renal Functionmentioning

confidence: 99%

The periprocedural management of novel oral anticoagulants in patients with nonvalvular atrial fibrillation: Rationale and a summary of the available evidence from phase 3 clinical trials

Krishnamoorthy

Sherwood

Lópes

et al. 2015

American Heart Journal

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Safety of Continuous Anticoagulation With Dabigatran During Implantation of Cardiac Rhythm Devices

Cited by 55 publications

References 24 publications

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

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

Oral anticoagulation management in patients with atrial fibrillation undergoing cardiac implantable electronic device implantation

The periprocedural management of novel oral anticoagulants in patients with nonvalvular atrial fibrillation: Rationale and a summary of the available evidence from phase 3 clinical trials

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