Use of Direct Oral Anticoagulants Following Cardiac Implantable Electronic Device Placement

Small studies have described the safety of uninterrupted direct oral anticoagulant (DOAC) use in atrial fibrillation (AF) patients undergoing elective, cardiac implantable electronic device (CIED) placement. Real-world practice patterns and associated outcomes remain poorly defined.

Describe DOAC usage trends following uncomplicated, outpatient CIED placement in AF patients and evaluate clinical outcomes based on DOAC status at discharge.

Using data from the National Cardiovascular Data Registry, AF patients with CHA₂DS₂-VASc ≥ 2 undergoing uncomplicated, outpatient CIED placement from April 2016 to December 2019 were stratified by DOAC prescription at discharge. Short and longer-term temporal trends and post-discharge outcomes were assessed using Centers for Medicare and Medicaid (CMS) claims.

Among 59,169 AF patients with elevated thromboembolic eligible for DOAC therapy who underwent elective, new CIED implant or generator replacement, 32,025 (54.1%) were discharged on a DOAC. Annual rates of DOAC use at discharge increased from 47.0% in 2016 to 62.5% in 2019 (p < 0.0001). Overall, patients discharged on DOAC had higher adjusted rates of pocket hematoma (0.51% vs. 0.33%, p = 0.0007) and lower rates of stroke (2.9% vs. 3.2%, p = 0.05) at 30-days but no significant differences in device infection or need for revision at 30-days or 1-year. Those undergoing new CIED implant had higher rates of pocket hematoma at 30-days (0.53% vs. 0.36%, p = 0.02) and need for device revision at 1-year (1.6% vs. 1.3%, p = 0.04).

In AF patients undergoing CIED implantation, about half were discharged on DOACs, with increasing rates of DOAC resumption immediately following post-CIED implantation over the study period. Those discharged on DOACs had modestly higher rates of pocket hematoma or need for device revision but similar risk of device infection.