Just Because You Can, Does That Mean You Should?

A growing number of patients undergoing implantation of cardiac devices are prescribed chronic oral anticoagulation therapy (OAC). It is estimated that 10% of patients undergoing pacemaker procedures1 and up to 25% of patients undergoing implantable cardiac defibrillators2 are taking OAC therapy. Hemorrhagic implant complications occur at a rate of 1.5%. Although this is a small percent, bleeding can lead to a significant increase in morbidity and mortality.3-5 The main indication for OAC (70%) is stroke prevention in the setting of atrial fibrillation (AF), with the remaining indications being mechanical valve, deep venous thrombosis, and pulmonary embolism.1,2,6,7 Management of periprocedural anticoagulation for patients requiring OAC is a frequent clinical dilemma for electrophysiologists, and is often a question posed from surgeons to electrophysiologists for patients undergoing a surgical procedure. For decades, warfarin was the only approved OAC. However, recently dabigatran, rivaroxaban, and apixaban have been approved for thromboembolic prophylaxis for AF. These agents have the unique property of reliable anticoagulation that does not require monitoring and reliable onset and elimination of the pharmacologic effect. Dabigatran is now recommended as an alternative to warfarin for OAC for nonvalvular AF.8 The increasing use of these OACs has raised further questions regarding OAC perioperative management, especially with lack of randomized trials or established guidelines. There are no American College of Cardiology or American Heart Association guidelines that address OAC management for device implantation. Traditionally, warfarin would be stopped several days before the implant date and a bridging strategy utilized either intravenous or subcutaneous heparin products until the INR was ≥2.0. Recent recommendations by the American College of Chest Physicians published in 20129 regarding the management of OAC at the time of a surgical procedure suggest to stop warfarin and to proceed with bridging anticoagulation in patients with a mechanical heart valve, AF or deep venous thrombosis, when the risk is considered high. The same guidelines call for no need for bridging when the risk is low. No specific recommendations

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