200 Bleeding Outcomes With Direct-Acting Oral Anticoagulants in Patients Undergoing Cardiac Device Implantation

Abstract

Over one third of patients undergoing permanent pacemaker or cardiac defibrillator implantation have an indication for therapeutic anticoagulation. Accumulating evidence supports continuation of warfarin therapy for these procedures. The evidence is less clear for direct acting oral anticoagulants (DOAC), medications now more commonly prescribed than warfarin. A best evidence topic was written according to a structured protocol addressing the question “does continuation of direct acting oral anticoagulants affect bleeding outcomes compared to discontinuation among patients undergoing cardiac pacemaker or defibrillator implantation?” Altogether, 1507 papers were found searching Medline, Embase, and Pubmed databases of which five represented the best evidence to answer the clinical question. Although modest evidence exists to answer this question, two recent randomised trials as well as two cohort studies and one case series have addressed the issue with similar findings. Interrupted and uninterrupted DOAC therapy resulted in similar rates of major bleeding (0-2.1% vs 0-4% respectively, no significant p-values reported) particularly in pocket haematoma formation, a clinically important event that substantially increases risk for infection and reoperation. Other adverse events reported were similar between the two groups. In well-selected patients at high risk for thromboembolic complications, it is reasonable to undertake cardiac device implantation without cessation of DOAC therapy as rates of bleeding complications are not significantly higher compared to interrupted therapy.