Morbidity associated with three different antiplatelet regimens in patients undergoing implantation of cardiac rhythm management devices

Abstract

Perioperative management of antiplatelet (AP) therapy in patients undergoing implantation of cardiac rhythm management devices (CRMD) remains an issue of concern that has not been prospectively evaluated in a large series. We sought to describe the morbidity associated with three different AP regimens in this setting. We conducted a prospective observational study including 849 consecutive patients who were classified in three groups according to the presence of any AP treatment: Group 1 (n= 220): single AP therapy; Group 2 (n= 60): dual AP therapy; and Group 3 (n= 40): oral anticoagulant (OAC) + enoxaparin 'bridging' + AP therapy. Two other groups served as controls: Group 4 (n= 375): no AP or OAC therapy; and Group 5 (n= 154): OAC + enoxaparin 'bridging'. The incidence of pocket haematoma, pocket revisions, hospital stays duration, and unscheduled follow-up visits due to pocket-related complications were compared. Patients on Groups 2, 3 and 5 had significantly higher incidences of pocket haematoma (13.3, 15, and 14.9%, respectively) when compared with Groups 1 and 4 (3.2 and 2.4%, respectively), as well as longer hospital stays and more unscheduled follow-up visits. Of note, only patients on enoxaparin 'bridging' required surgical revision of the pocket. Dual AP therapy (P< 0.001), enoxaparin 'bridging' (P< 0.001) and renal insufficiency (P= 0.02) were independent predictors of pocket haematoma in multivariate analysis. Dual AP therapy and OAC + AP therapy is strongly associated with a significant risk of pocket haematoma, longer hospital stays, and unscheduled follow-up visits. Importantly, surgical revision of the pocket was associated with enoxaparin 'bridging' strategy but was never necessary in patients taking exclusively antiaggregant agents.