DOACs vs Vitamin K Antagonists During Cardiac Rhythm Device Surgery: A Multicenter Propensity-Matched Study.

Area of Science:

• Cardiology
• Pharmacology
• Medical Devices

Background:

• Limited data exists comparing vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) for patients undergoing cardiac implantable electronic device (CIED) surgery.
• Optimal management of DOACs (interruption versus continuation) around CIED procedures remains undetermined.

Purpose of the Study:

• To compare bleeding and thrombotic event rates based on anticoagulant type (DOAC vs. VKA) and management strategy (interrupted vs. uninterrupted).
• To identify predictors of major bleeding in patients undergoing CIED surgery.

Main Methods:

• An observational, multicenter study included patients on chronic oral anticoagulation undergoing CIED surgery.
• Propensity score matching was used to create comparable groups.
• Included 1,975 patients, with a matched population of 861.

Main Results:

• A continued DOAC strategy was associated with a higher rate of major bleeding (5.2%) compared to interrupted DOAC (1.7%) and continued VKA (2.1%).
• DOAC interruption was linked to an increased risk of perioperative thromboembolism (1.4%), while no events occurred with DOAC or VKA continuation.
• Dual antiplatelet therapy, DOAC continuation, and male sex independently predicted major bleeding.

Conclusions:

• Continuing DOACs in CIED surgery patients increases bleeding risk compared to interruption or VKA use.
• Interrupting DOACs elevates thromboembolic risk.
• Avoiding concomitant dual antiplatelet therapy is recommended; a strategy of minimal DOAC interruption appears to be the optimal compromise.