Interrupted versus uninterrupted anticoagulation for cardiac rhythm management device insertion

Area of Science:

• Cardiology
• Pharmacology
• Medical Devices

Background:

• Strategies for perioperative anticoagulation interruption during cardiac implantable electronic device (CIED) surgery vary globally.
• Uncertainty exists regarding the benefits and harms of interrupted versus uninterrupted anticoagulation for CIED surgery.

Purpose of the Study:

• To evaluate the benefits and harms of interrupted anticoagulation (IAC) versus uninterrupted anticoagulation (UAC) in patients undergoing CIED surgery.
• To compare IAC with either warfarin or direct oral anticoagulants (DOACs) against UAC, with or without heparin bridging.

Main Methods:

• Systematic review and meta-analysis of randomized controlled trials (RCTs).
• Included studies compared IAC versus UAC in adults undergoing elective CIED surgery on warfarin or DOACs.
• Primary outcomes included composite thromboembolic events and device-pocket hematoma; secondary outcomes included bleeding events and mortality.

Main Results:

• For warfarin, IAC showed little to no difference in composite thromboembolic events (low-certainty evidence) and very uncertain effects on device-pocket hematoma and bleeding (very low-certainty evidence).
• For DOACs, IAC also demonstrated little to no difference in composite thromboembolic events and ischemic stroke (low-certainty evidence), with very uncertain effects on device-pocket hematoma and bleeding (very low-certainty evidence).
• Moderate-certainty evidence suggested little to no difference in deep vein thrombosis or pulmonary embolism for both warfarin and DOACs.

Conclusions:

• Interrupted anticoagulation for elective CIED surgery yielded similar outcomes to uninterrupted anticoagulation for both warfarin and DOACs.
• The certainty of evidence for most outcomes was low to very low.
• Further RCTs are crucial to clarify the impact of interrupted anticoagulation on thromboembolic events and device-pocket hematoma.