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Published on: February 26, 2013
Continuing warfarin therapy is superior to interrupting warfarin with or without bridging anticoagulation therapy in
Imdad Ahmed1, Elie Gertner, William B Nelson
1Department of Medicine, Regions Hospital and the University of Minnesota Medical School, Saint Paul, Minnesota 55101, USA.
Insights
Continuing warfarin therapy during pacemaker or defibrillator implantation is safe and effective. This approach reduces thromboembolic events and hospital stays compared to interrupting anticoagulation or using bridging therapy.
Area of Science:
- Cardiology
- Electrophysiology
- Anticoagulation Therapy
Background:
- Current guidelines advise stopping oral anticoagulation before pacemaker/defibrillator surgery.
- Bridging anticoagulation with heparin or enoxaparin is recommended for high-risk patients.
- Feasibility of device surgery without oral anticoagulation cessation is under investigation.
Purpose of the Study:
- To assess the safety of continuing warfarin during device implantation.
- To compare outcomes of continuing warfarin versus interruption with or without bridging therapy.
Main Methods:
- Retrospective study of 459 warfarin-treated patients undergoing device surgery.
- Three groups: warfarin continued (n=222), warfarin held with bridging (n=123), warfarin held without bridging (n=114).
- Data collected on perioperative management and clinical outcomes.
Main Results:
- No significant differences in age, sex, or thromboembolic risk factors across groups.
- Continuing warfarin associated with lower pocket hematoma incidence and shorter hospital stay versus bridging.
- Holding warfarin without bridging increased transient ischemic attack risk.
Conclusions:
- Interrupting anticoagulation increases thromboembolic events.
- Warfarin cessation with bridging leads to more hematomas and longer hospital stays.
- Continuing warfarin with a therapeutic INR is safe, cost-effective for high-risk patients undergoing device implantation.
Background:
Current guidelines recommend stopping oral anticoagulation and starting bridging anticoagulation with intravenous heparin or subcutaneous enoxaparin when implanting a pacemaker or defibrillator in patients at moderate or high risk for thromboembolic events. A limited body of literature suggests that device surgery without cessation of oral anticoagulation may be feasible.
Objective:
The purpose of this study was to evaluate the safety of device surgery in orally anticoagulated patients without interrupting warfarin therapy.
Methods:
We performed a retrospective study of 459 consecutive patients on chronic warfarin therapy who underwent device surgery from April 2004 to September 2008. Warfarin was continued in 222 patients during the perioperative period. Warfarin was temporarily held and bridging therapy administered in 123 patients. Warfarin was temporarily held without bridging therapy in 114 patients.
Results:
There were no significant differences with regard to age, sex, or risk factors for thromboembolism in the three groups. Patients who continued taking warfarin had a lower incidence of pocket hematoma (P = .004) and a shorter hospital stay (P <.0001) than did patients in the bridging group. Holding warfarin without bridging is associated with a higher incidence of transient ischemic attacks (P = .01).
Conclusion:
Temporarily interrupting anticoagulation is associated with increased thromboembolic events, whereas cessation of warfarin with bridging anticoagulation is associated with a higher rate of pocket hematoma and a longer hospital stay. Continuing warfarin with a therapeutic international normalized ratio appears to be a safe and cost-effective approach when implanting a pacemaker or defibrillator in patients with moderate to high thromboembolic risk.
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