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Abdelnabi M, Benjanuwattra J, Okasha O, Almaghraby A, Saleh Y, Gerges F. Switching from warfarin to direct-acting oral anticoagulants: it is time to move forward! Egypt Heart J 2022; 74:18. [PMID: 35347478 PMCID: PMC8960500 DOI: 10.1186/s43044-022-00259-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/20/2022] [Indexed: 11/12/2022] Open
Abstract
Oral vitamin K antagonists (VKAs), warfarin, have been in routine clinical use for almost 70 years for various cardiovascular conditions. Direct-Acting Oral Anticoagulants (DOACs) have emerged as competitive alternatives for VKAs to prevent stroke in patients with non-valvular atrial fibrillation (AF) and have become the preferred choice in several clinical indications for anticoagulation. Recent guidelines have limited the use of DOACs to patients with non-valvular AF to reduce the risk of cardioembolic complications and to treat venous thromboembolism (VTE). Although emerging evidence is suggestive of its high efficacy, there was a lack of data to support DOACs safety profile in patients with mechanical valve prosthesis, intracardiac thrombi, or other conditions such as cardiac device implantation or catheter ablation. Therefore, several clinical trials have been conducted to assess the beneficial effects of using DOACs, instead of VKAs, for various non-guideline-approved indications. This review aimed to discuss the current guideline-approved indications for DOACs, advantages, and limitations of DOACs use in various clinical indications highlighting the potential emerging indications and remaining challenges for DOACs use. Several considerations are in favour of switching from warfarin to DOACs including superior efficacy, better adverse effect profile, fewer drug-drug interactions, and they do not require frequent international normalized ratio (INR) monitoring. Large randomized controlled trials are required to determine the safety and efficacy of their use in various clinical indications.
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Affiliation(s)
- Mahmoud Abdelnabi
- Internal Medicine Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA. .,Cardiology and Angiology Unit, Clinical and Experimental Internal Medicine Department, Alexandria University, Alexandria, Egypt.
| | - Juthipong Benjanuwattra
- Internal Medicine Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Osama Okasha
- Internal Medicine Department, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Abdallah Almaghraby
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yehia Saleh
- Cardiology Department, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Fady Gerges
- Department of Cardiovascular Science, Mediclinic Al Jowhara Hospital, Al Ain, UAE
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Ono K, Iwasaki YK, Akao M, Ikeda T, Ishii K, Inden Y, Kusano K, Kobayashi Y, Koretsune Y, Sasano T, Sumitomo N, Takahashi N, Niwano S, Hagiwara N, Hisatome I, Furukawa T, Honjo H, Maruyama T, Murakawa Y, Yasaka M, Watanabe E, Aiba T, Amino M, Itoh H, Ogawa H, Okumura Y, Aoki-Kamiya C, Kishihara J, Kodani E, Komatsu T, Sakamoto Y, Satomi K, Shiga T, Shinohara T, Suzuki A, Suzuki S, Sekiguchi Y, Nagase S, Hayami N, Harada M, Fujino T, Makiyama T, Maruyama M, Miake J, Muraji S, Murata H, Morita N, Yokoshiki H, Yoshioka K, Yodogawa K, Inoue H, Okumura K, Kimura T, Tsutsui H, Shimizu W. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. Circ J 2022; 86:1790-1924. [DOI: 10.1253/circj.cj-20-1212] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Masaharu Akao
- Department of Cardiovascular Medicine, National Hospital Organization Kyoto Medical Center
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
| | - Kuniaki Ishii
- Department of Pharmacology, Yamagata University Faculty of Medicine
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | | | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | | | - Tetsushi Furukawa
- Department of Bio-information Pharmacology, Medical Research Institute, Tokyo Medical and Dental University
| | - Haruo Honjo
- Research Institute of Environmental Medicine, Nagoya University
| | - Toru Maruyama
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital
| | - Yuji Murakawa
- The 4th Department of Internal Medicine, Teikyo University School of Medicine, Mizonokuchi Hospital
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University School of Medicine
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mari Amino
- Department of Cardiovascular Medicine, Tokai University School of Medicine
| | - Hideki Itoh
- Division of Patient Safety, Hiroshima University Hospital
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organisation Kyoto Medical Center
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Chizuko Aoki-Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Komatsu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University School of Medicine
| | | | | | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | - Yukio Sekiguchi
- Department of Cardiology, National Hospital Organization Kasumigaura Medical Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Noriyuki Hayami
- Department of Fourth Internal Medicine, Teikyo University Mizonokuchi Hospital
| | | | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University, Faculty of Medicine
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Mitsunori Maruyama
- Department of Cardiovascular Medicine, Nippon Medical School Musashi Kosugi Hospital
| | - Junichiro Miake
- Department of Pharmacology, Tottori University Faculty of Medicine
| | - Shota Muraji
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | | | - Norishige Morita
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
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Fei YP, Wang L, Zhu CY, Sun JC, Hu HL, Zhai CL, He CJ. Effect of a Novel Pocket Compression Device on Hematomas Following Cardiac Electronic Device Implantation in Patients Receiving Direct Oral Anticoagulants. Front Cardiovasc Med 2022; 9:817453. [PMID: 35282349 PMCID: PMC8907568 DOI: 10.3389/fcvm.2022.817453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/02/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundA pocket hematoma is a well-recognized complication that occurs after pacemaker or defibrillator implantation. It is associated with increased pocket infection and hospital stay. Patients suffering from atrial fibrillation and undergoing cardiovascular electronic implantable device (CIED) surgery are widely prescribed and treated with direct oral anticoagulants (DOACs). In this study, the use of a novel compression device was evaluated to examine its ability to decrease the incidence of pocket hematomas following device implantation with uninterrupted DOACs.MethodsA total of 204 participants who received DOACs and underwent CIED implantation were randomized into an experimental group (novel compression device) and a control group (elastic adhesive tape with a sandbag). The primary outcome was pocket hematoma, and the secondary outcomes were skin erosions and patient comfort score. Grade 3 hematoma was defined as a hematoma that required anticoagulation therapy interruption, re-operation, or prolonged hospital stay.ResultsThe baseline characteristics of both groups had no significant differences. The incidence of grades 1 and 2 hematomas was significantly lower in the compression device group than in the conventional pressure dressing group (7.8 vs. 23.5 and 2.0 vs. 5.9%, respectively; P < 0.01). Grade 3 hematoma occurred in 2 of 102 patients in the experimental group and 7 of 102 patients in the control group (2.0 vs. 6.9%; P = 0.03). The incidence rates of skin erosion were significantly lower, and the patient comfort score was much higher in the compression device group than in the control group (P < 0.01). Multivariable logistic regression analysis showed that the use of novel compression device was a significant protective factor for pocket hematoma (OR = 0.42; 95% CI, 0.29–0.69, P = 0.01).ConclusionsThe incidence of pocket hematomas and skin erosions significantly decreases when the proposed compression device is used for patients undergoing device implantation with uninterrupted DOACs. Thus, the length of hospital stay and re-operation rate can be reduced, and patient comfort can be improved.Clinical Trial Registrationhttp://www.chictr.org.cn, identifier: ChiCTR2100049430.
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Affiliation(s)
- Ye-Ping Fei
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Lei Wang
- Department of General Practice, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Chun-Yan Zhu
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Jing-Chao Sun
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Hui-Lin Hu
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Chang-Lin Zhai
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Chao-Jie He
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
- *Correspondence: Chao-Jie He
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van der Wall SJ, Lip GYH, Teutsch C, Kalejs O, Lyrer P, Hall C, Dubner SJ, Diener HC, Halperin JL, Ma CS, Rothman KJ, Zint K, Zhai D, Huisman MV. Low bleeding and thromboembolic risk with continued dabigatran during cardiovascular interventions: the GLORIA-AF study. Eur J Intern Med 2021; 91:75-80. [PMID: 34120814 DOI: 10.1016/j.ejim.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prospective data on nonvitamin-K-antagonist oral anticoagulant (NOAC) management during cardiovascular interventions are limited. We therefore evaluated the safety and effectiveness of uninterrupted dabigatran therapy as well as dabigatran management during atrial fibrillation (AF)-cardioversions, AF-ablations, pacemaker implantations and coronary angiography and/or stenting procedures. METHOD GLORIA-AF is an international registry programme involving patients with newly diagnosed AF. Dabigatran users were followed for ≤2 years. The primary outcome was occurrence of stroke/systemic embolism and major bleeding ≤8 weeks after a cardiovascular intervention during uninterrupted dabigatran therapy. RESULTS During the 2-year follow-up, 599 cardiovascular interventions were identified in 479 eligible patients. 412/599 (69%) interventions were performed with uninterrupted dabigatran therapy: 299/354 (84%) AF-cardioversions, 38/89 (43%) AF-ablations, 25/58 (43%) pacemaker implantations, and 50/98 (51%) coronary angiography and/or stenting procedures. During an average follow-up of 8.4 weeks after intervention, one major bleed and one systemic embolic event occurred (risk 0.25% for both outcomes; 95% confidence interval, 0.01%-1.36%). CONCLUSIONS More than two thirds of the interventions were performed with uninterrupted dabigatran therapy, of which most were AF-cardioversions. Uninterrupted dabigatran therapy was associated with low major bleeding and stroke/systemic embolism risk, supporting the favourable safety and effectiveness profile of dabigatran in clinical practice-based settings.
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Affiliation(s)
- Sake J van der Wall
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, OLVG Hospital, Amsterdam, the Netherlands.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christine Teutsch
- Department of CardioMetabolism and Respiratory Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Oskars Kalejs
- Department of Arrhythmology, Pauls Stradins Clinic University Hospital Pilsonuiela, Riga, Latvia
| | - Philippe Lyrer
- Department of Neurology, Universitatsspital Basel, Basel, Switzerland
| | - Christian Hall
- Department of Medical Research, Vestre Viken HF, Honefoss, Norway
| | - Sergio J Dubner
- Clínica y Maternidad Suizo Argentina, Buenos Aires, Argentina
| | | | | | - Chang Sheng Ma
- Cardiology Department, Atrial Fibrillation Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kenneth J Rothman
- RTI Health Solutions, Research Triangle Institute, Research Triangle Park, NC, United States
| | - Kristina Zint
- Global Epidemiology Department, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Dongmei Zhai
- Biostatistics and Data Sciences Department, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, United State
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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5
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Tonko JB, Wright MJ. Continuation Versus Interruption of Direct Oral Anticoagulants for CIED Procedures: New Anticoagulants, Old Dilemma. JACC Case Rep 2021; 3:1141-1144. [PMID: 34471900 PMCID: PMC8314125 DOI: 10.1016/j.jaccas.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Johanna B. Tonko
- Department of Cardiology, St Thomas’ Hospital, London, United Kingdom
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London, United Kingdom
| | - Matthew J. Wright
- Address for correspondence: Dr Matthew J. Wright, Department of Cardiology, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, United Kingdom.
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Mehta NK, Doerr K, Skipper A, Rojas-Pena E, Dixon S, Haines DE. Current strategies to minimize postoperative hematoma formation in patients undergoing cardiac implantable electronic device implantation: A review. Heart Rhythm 2020; 18:641-650. [PMID: 33242669 DOI: 10.1016/j.hrthm.2020.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/04/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023]
Abstract
There are an increasing number of cardiac electronic device implants and generator changes with a longer patient life expectancy along with concomitant increase in antiplatelet and anticoagulant regimens, which can increase the incidence of pocket hematomas. We have conducted an in-depth analysis on the relevant literature, which is rife with varying definition of hematomas, on ways to reduce pocket hematomas. We have analyzed studies on periprocedural medication management, intraprocedural use of prohemostatic agents, and postprocedure role of compression devices.
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Affiliation(s)
- Nishaki Kiran Mehta
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan; Oakland University William Beaumont School of Medicine, Rochester, Michigan; Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia.
| | - Kimberly Doerr
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Andrew Skipper
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Edward Rojas-Pena
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Simon Dixon
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan; Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - David E Haines
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan; Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
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Non-vitamin K oral anticoagulants at the time of cardiac rhythm device surgery: A systematic review and meta-analysis. Thromb Res 2020; 188:90-96. [DOI: 10.1016/j.thromres.2020.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 11/21/2022]
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Ferretto S, Mattesi G, Migliore F, Susana A, De Lazzari M, Iliceto S, Leoni L, Bertaglia E. Clinical predictors of pocket hematoma after cardiac device implantation and replacement. J Cardiovasc Med (Hagerstown) 2019; 21:123-127. [PMID: 31789710 DOI: 10.2459/jcm.0000000000000914] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIMS Pocket hematoma is a common complication of cardiac implantable electronic device (CIED) procedures. the aim of the study was to research the clinical factors associated with pocket hematoma formation after CIED implantation or replacement and to identify the best perioperative antithrombotic management. METHODS We retrospectively analyzed 500 consecutive patients who underwent to CIED implantation or replacement at our center from November 2014. RESULTS Among our population, 206 patients (41.2%) were on anticoagulant therapy at the time of the intervention: 68 (13.6%) on ongoing Warfarin; 111 (22.2%) on low-molecular-weight heparin (LMWH); and 27 (5.4%) on ongoing direct oral anticoagulants. Antiplatelet therapy was present in 262 (52.4%) patients: in particular, 50 (10%) were on dual antiplatelet therapy, 64 (12.8%) were on single antiplatelet therapy and anticoagulant therapy, whereas 12 (2.4%) were on anticoagulant with dual antiplatelet therapy.Incidence of pocket hematoma after CIEDs implantation was of 4.6%. Considering the different perioperative anticoagulant strategies, patients on LMWH presented the higher hematoma rate [11/100 patients (11.0%), P < 0.001]. At the multivariate analysis, anticoagulant with dual antiplatelet therapy (P = 0.021, OR 6.3, IC 1.3-30.8), left ventricular ejection fraction (LVEF) less than 30% (P < 0.001, OR 7.4, IC 2.7-20.4), and use of LMWH (P = 0.008, OR 3.8, IC 1.4-10.6) resulted the strongest predictors of pocket hematoma (Hosmer test = 0.899).Considering replacement procedures, incidence of pocket hematoma was of 4.4%. The incidence was higher after ICD/CRT-D replacement. The majority of pocket hematoma occurred in patients with mechanical valve prosthesis (3/4 cases, 75%, P < 0.001). CONCLUSION The use of LMWH and a low LVEF expose patients to a higher risk of pocket hematoma after CIED procedures. Anticoagulant with dual antiplatelet therapy and LMWH should be avoided.
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Affiliation(s)
- Sonia Ferretto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua.,Department of Cardiology, San Donà di Piave Hospital, Venice, Italy
| | - Giulia Mattesi
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
| | - Federico Migliore
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
| | - Angela Susana
- Department of Cardiology, Cittadella Hospital, Padua, Italy
| | - Manuel De Lazzari
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
| | - Loira Leoni
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
| | - Emanuele Bertaglia
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
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Pillarisetti J, Maybrook R, Parikh V, Adabala N, Khalafi M, Reddy S, Bommana S, Lakkireddy P, Reddy MY, Gianni C, Gopinathannair R, Mohanty S, Di Biase L, Natale A, Saksena S, Lakkireddy D. Peri-procedural use of direct anticoagulation agents during cardiac device implantation: vitamin K antagonists vs direct oral anticoagulants. J Interv Card Electrophysiol 2019; 58:141-146. [PMID: 31732839 DOI: 10.1007/s10840-019-00646-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Warfarin is deemed safe compared to bridging with heparin in the peri-procedure setting while implanting cardiac devices. The timing of discontinuation and re-initiation of direct anticoagulant agents (DOACs) such as dabigatran, apixaban, and rivaroxaban in the peri-procedural setting in comparison to warfarin is not well studied. OBJECTIVE We wanted to compare three DOAC agents with warfarin during cardiac device implantation. METHODS Consecutive patients on treatment with dabigatran, rivaroxaban, or apixaban (group A) undergoing a cardiac device generator change, upgrade, or new implantation procedure were compared to those on warfarin (group B). Incidence of hematoma, infection, effusion, stroke, and other complications were noted at 1 day, 1 week, and 3 months. RESULTS A total of 311 patients in group A underwent the above procedures with 73 patients on dabigatran, 153 on rivaroxaban, and 85 on apixaban. There were 467 patients on warfarin in group B. Mean age of the total population was 68 ± 12 years with 67% males and > 80% Caucasians. The last dose of the DOAC was the night prior to the procedure and resumed the night of the procedure (single dose interruption for apixaban and dabigatran and no un-interruption for rivaroxaban). There was no difference noted in the incidence of minor or major hematoma (9% vs 8.5%, p = 0.7). No stroke occurred in either group. CONCLUSION Use of DOAC agents with transient interruption of one dose is as safe as warfarin in the peri-procedural setting during implantation of cardiac devices.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Rakesh Gopinathannair
- Division of Cardiovascular Diseases, Kansas City Heart Rhythm Institute, 5100 W 110th St Second Floor, Overland Park, KS, 66211, USA
| | | | | | | | - Sanjeev Saksena
- UMDNJ-Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Kansas City Heart Rhythm Institute, 5100 W 110th St Second Floor, Overland Park, KS, 66211, USA.
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Tsai CT, Liao JN, Chao TF, Lin YJ, Chang SL, Lo LW, Hu YF, Chung FP, Tuan TC, Chen SA. Uninterrupted non-vitamin K antagonist oral anticoagulants during implantation of cardiac implantable electronic devices in patients with atrial fibrillation. J Chin Med Assoc 2019; 82:256-259. [PMID: 30946706 DOI: 10.1097/jcma.0000000000000050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND For patients with atrial fibrillation (AF) receiving cardiac implantable electronic device (CIED) implantations, current consensus recommends uninterrupted non-vitamin K antagonist oral anticoagulant (NOAC) considering low incidence of bleeding or thrombo-embolic events. It remains unknown whether uninterrupted strategy outweighs discontinuation method for patients receiving NOAC. METHODS From January 1, 2013 to June 1, 2017, we enrolled 100 patients (mean age 78.3 ± 10.2 years, 58% male) with AF taking NOAC for stroke prevention eligible for CIED implantation in a tertiary medical center, Taipei, Taiwan. NOAC was continued without skipping any doses during the surgery. The baseline characteristics, underlying diseases, CHA2DS2-VASc score, and clinical course of every patient were reviewed and analyzed. RESULTS Among these patients, 28 were on dabigatran, 61 on rivaroxaban, 10 on apixaban, and one on edoxaban, respectively. There were no adverse events except one case of pericardial effusion and another one with large pocket hematoma. One patient receiving implantable cardioverter defibrillator implantation had late onset of pericardial effusion with impending tamponade necessitating pericardiocentesis. Another patient had large pocket hematoma, which spontaneously resolved within 1 month without further intervention. No periprocedural mortality and stroke occurred. CONCLUSION Uninterrupted NOAC during CIED implantations may be an acceptable option especially in patients with high risk for thromboembolism. However, special caution should be paid during defibrillator implantation considering relatively higher risk of bleeding, perhaps due to the larger size of the defibrillator lead.
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Affiliation(s)
- Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Cardiology, Taipei Municipal Gan-Dau Hospital, Taipei, Taiwan, ROC
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
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11
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Ricciardi D, Creta A, Colaiori I, Scordino D, Ragni L, Picarelli F, Calabrese V, Providência R, Ioannou A, Di Sciascio G. Interrupted versus uninterrupted novel oral anticoagulant peri-implantation of cardiac device: A single-center randomized prospective pilot trial. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1476-1480. [DOI: 10.1111/pace.13482] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/28/2018] [Accepted: 06/20/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Danilo Ricciardi
- Campus Bio-Medico; Unit of Cardiology; University of Rome; Rome Italy
| | - Antonio Creta
- Campus Bio-Medico; Unit of Cardiology; University of Rome; Rome Italy
- Barts Heart Centre; St. Bartholomew's Hospital; London United Kingdom
| | - Iginio Colaiori
- Campus Bio-Medico; Unit of Cardiology; University of Rome; Rome Italy
| | - Domenico Scordino
- Campus Bio-Medico; Unit of Cardiology; University of Rome; Rome Italy
| | - Laura Ragni
- Campus Bio-Medico; Unit of Cardiology; University of Rome; Rome Italy
| | | | - Vito Calabrese
- Campus Bio-Medico; Unit of Cardiology; University of Rome; Rome Italy
| | - Rui Providência
- Barts Heart Centre; St. Bartholomew's Hospital; London United Kingdom
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12
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Essebag V, Proietti R, Birnie DH, Wang J, Douketis J, Coutu B, Parkash R, Lip GYH, Hohnloser SH, Moriarty A, Oldgren J, Connolly SJ, Ezekowitz M, Healey JS. Short-term dabigatran interruption before cardiac rhythm device implantation: multi-centre experience from the RE-LY trial. Europace 2018; 19:1630-1636. [PMID: 28339794 DOI: 10.1093/europace/euw409] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/06/2016] [Indexed: 02/03/2023] Open
Abstract
Aims Cardiac implantable electronic device (CIED) surgery is commonly performed in patients with atrial fibrillation (AF). The current analysis was undertaken to compare peri-operative anticoagulation management, bleeding, and thrombotic events in AF patients treated with dabigatran vs. warfarin. Methods and results This study included 611 patients treated with dabigatran vs. warfarin who underwent CIED surgery during the RE-LY trial. Among 201 warfarin-treated patients, warfarin was interrupted a median of 144 (inter-quartile range, IQR: 120-216) h, and 37 (18.4%) patients underwent heparin bridging. In dabigatran-treated patients (216 on 110 mg bid and 194 on 150 mg bid), the duration of dabigatran interruption was a median of 96 (IQR: 61-158) h. Pocket hematomas occurred in 9 (2.20%) patients on dabigatran and 8 (3.98%) patients on warfarin (P = 0.218). The occurrence of pocket hematomas was lower with dabigatran compared with warfarin with heparin bridging (RD: -8.62%, 95% CI: -24.15 to - 0.51%, P = 0.034) but not when compared with warfarin with no bridging (P = 0.880). Ischemic stroke occurred in 2 (0.3%) patients; one in the warfarin group (without bridging) and one in the dabigatran 150 mg bid group (P = 0.735). Conclusion In patients treated with dabigatran undergoing CIED surgery, interruption of dabigatran is associated with similar or lower incidence of pocket hematoma, when compared with warfarin interruption without or with heparin bridging, respectively. Whether uninterrupted dabigatran can reduce pocket hematoma or ischemic stroke remains to be evaluated.
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Affiliation(s)
- Vidal Essebag
- McGill University Health Center, 1650 Cedar Ave, Room E5-200, Montreal, QC, Canada H3G 1A4.,Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada
| | - Riccardo Proietti
- Cardiology Department, Morriston Hospital, Swansea University, Heol Maes Eglwys, Morriston, Swansea SA6 6NL, UK.,Cardiology Department, Luigi Sacco Hospital, Milan, Italy
| | - David H Birnie
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Jia Wang
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - James Douketis
- St. Joseph's Healthcare, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Benoit Coutu
- Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Ratika Parkash
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | | | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Michael Ezekowitz
- Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA, USA
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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13
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Sheldon SH, Cunnane R, Lavu M, Parikh V, Atkins D, Reddy YM, Berenbom LD, Emert MP, Pimentel R, Dendi R, Lakkireddy DR. Perioperative hematoma with subcutaneous ICD implantation: Impact of anticoagulation and antiplatelet therapies. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:799-806. [DOI: 10.1111/pace.13349] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/05/2018] [Accepted: 03/25/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Seth H. Sheldon
- Division of Cardiovascular DiseasesUniversity of Kansas Medical Center Kansas City KS USA
| | - Ryan Cunnane
- Division of Cardiovascular DiseasesUniversity of Michigan Ann Arbor MI USA
| | - Madhav Lavu
- Division of Cardiovascular DiseasesUniversity of Kansas Medical Center Kansas City KS USA
| | - Valay Parikh
- Division of Cardiovascular DiseasesUniversity of Kansas Medical Center Kansas City KS USA
| | - Donita Atkins
- Division of Cardiovascular DiseasesUniversity of Kansas Medical Center Kansas City KS USA
| | - Yeruva Madhu Reddy
- Division of Cardiovascular DiseasesUniversity of Kansas Medical Center Kansas City KS USA
| | - Loren D. Berenbom
- Division of Cardiovascular DiseasesUniversity of Kansas Medical Center Kansas City KS USA
| | - Martin P. Emert
- Division of Cardiovascular DiseasesUniversity of Kansas Medical Center Kansas City KS USA
| | - Rhea Pimentel
- Division of Cardiovascular DiseasesUniversity of Kansas Medical Center Kansas City KS USA
| | - Raghuveer Dendi
- Division of Cardiovascular DiseasesUniversity of Kansas Medical Center Kansas City KS USA
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14
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Periprocedural Management of Direct Oral Anticoagulants Surrounding Cardioversion and Invasive Electrophysiological Procedures. Cardiol Rev 2018; 26:245-254. [PMID: 29621010 PMCID: PMC6082596 DOI: 10.1097/crd.0000000000000188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Supplemental Digital Content is available in the text. As direct oral anticoagulants (DOACs) have demonstrated favorable efficacy and safety outcomes compared with vitamin K antagonists for the treatment and prevention of venous thromboembolism and the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, their role in the management of anticoagulation during electrophysiological procedures continues to evolve. At present, guidelines are limited regarding specific recommendations for the use of DOACs in these clinical settings. Here, we review available data regarding the risks and benefits associated with various periprocedural anticoagulation management approaches when patients receiving DOACs undergo electrophysiologic procedures including cardioversion, ablation, and device implantation. This discussion is intended to provide clinicians with an overview of available evidence and best practices to minimize the risk of both thromboembolic and bleeding events in the periprocedural setting.
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15
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Stewart MH, Morin DP. Management of Perioperative Anticoagulation for Device Implantation. Card Electrophysiol Clin 2018; 10:99-109. [PMID: 29428146 DOI: 10.1016/j.ccep.2017.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Periprocedural management of anticoagulation for cardiac device implantation has evolved over the past 20 years. The traditional paradigm of vitamin K antagonist interruption with heparin bridging has now been shown to be less safe than continuation of vitamin K antagonists at therapeutic levels. Dual antiplatelet therapy during device implantation poses substantial risk but is often necessary. The safest dosing strategy for newer direct oral anticoagulants is still not clear.
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Affiliation(s)
- Merrill H Stewart
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Daniel P Morin
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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16
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Worsnick SA, Vijayaraman P. How To Manage Oral Anticoagulation Periprocedurally During Ablations And Device Implantations. J Atr Fibrillation 2017; 9:1500. [PMID: 29250258 DOI: 10.4022/jafib.1500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 11/26/2016] [Accepted: 12/14/2016] [Indexed: 11/10/2022]
Abstract
More than 150, 000 patients undergo ablation for atrial fibrillation (AF) each year.Current guidelines recommend oral anticoagulation in all patients undergoing AF ablation. A large number of patients undergoing cardiac implantable electronic devices (CIEDs) are on long-term oral anticoagulation. These patients are at increased risk for thromboembolism with interruption of oral anticoagulation. Due to the increased risk for bleeding complications during the procedure combined with the need to prevent thromboembolism, periprocedural management of anticoagulation in these patients can be challenging. In this article we review the current evidence for periprocedural management of oral anticoagulation in patients undergoing ablation and CIED implantation.
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17
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Chousou PA, Pugh PJ. Managing anticoagulation in patients receiving implantable cardiac devices. Future Cardiol 2017; 14:151-164. [PMID: 29226707 DOI: 10.2217/fca-2017-0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A substantial proportion of patients who undergo cardiac device implantation receive oral anticoagulation to prevent thromboembolism or antiplatelets to prevent thrombotic events. Anticoagulation and antiplatelets increase the risk of hemorrhagic complications, while discontinuation may increase thromboembolic risk and thrombotic events. With the introduction of non-vitamin K antagonist oral anticoagulant agents and the newer antiplatelet agents such as prasugrel or ticagrelor, the perioperative management of patients has become more challenging. In this article, we review the recent trials and meta-analysis and describe the available evidence, as well as the current recommendations in order to inform best practice. We also reinforce the importance of further trials in this complex and rapidly evolving area.
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Affiliation(s)
- Panagiota Anna Chousou
- Department of Cardiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - Peter J Pugh
- Department of Cardiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
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18
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He H, Ke BB, Li Y, Han FS, Li X, Zeng YJ. Perioperative management of antithrombotic therapy in patients receiving cardiovascular implantable electronic devices: a network meta-analysis. J Interv Card Electrophysiol 2017; 50:65-83. [PMID: 28842832 DOI: 10.1007/s10840-017-0280-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/10/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Network meta-analysis (NMA) has advantages including being able to simultaneously compare and rank multiple treatments over traditional meta-analysis. We evaluated by a NMA the optimal antithrombotic strategy during the perioperative period of implantation of cardiovascular implantable electronic devices (CIEDs). METHODS We performed a network meta-analysis of observational studies (cohort and case-control studies). The eligible studies tested the following antithrombotic therapy during the CIED placement: aspirin, clopidogrel, warfarin, novel oral anticoagulants (NOACs), and heparin bridging. RESULTS Thirty-one observational studies with 119 study arms were included (41,174 patients receiving long-term antithrombotic therapy; median age, 72.6 years; 70.1% males; median follow-up, 3.6 years). Aspirin (4.26 [2.88-7.22]), warfarin (3.37 [2.17-5.23]), and clopidogrel (3.30 [1.49-5.88]) reduced the risk of bleeding as compared with heparin bridging, and there was no significance difference between continued NOACs and heparin bridging (0.67 [0.21-2.18]). The comparison of commonly used protocols in the management of anticoagulant therapy revealed that continued warfarin (0.38 [0.20-0.74]), continued NOACs (0.19 [0.04-0.89]), and heparin bridging therapy (0.01 [0.05-0.21]) increased the risk of bleeding as compared that of control, and continued warfarin (3.74 [1.96-7.16]), interrupted warfarin (4.89 [2.20-10.88]), and interrupted NOACs (12.5 [1.25-100]) reduced the risk of bleeding compared with that of heparin bridging. CONCLUSIONS Among various antithrombotic drugs, aspirin had the lowest bleeding risk, followed by warfarin, clopidogrel and NOACs, and heparin, with the greatest bleeding risk. NOACs therapy appears safe and effective, and interrupted NOACs may be the optimal anticoagulation protocol for use during the perioperative period of CIED implantation.
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Affiliation(s)
- Hua He
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China.
| | - Bing-Bing Ke
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yan Li
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, 100029, China
| | - Fu-Sheng Han
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Xiaodong Li
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yu-Jie Zeng
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
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19
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Deharo JC, Sciaraffia E, Leclercq C, Amara W, Doering M, Bongiorni MG, Chen J, Dagres N, Estner H, Larsen TB, Johansen JB, Potpara TS, Proclemer A, Pison L, Brunet C, Blomström-Lundqvist C. Perioperative management of antithrombotic treatment during implantation or revision of cardiac implantable electronic devices: the European Snapshot Survey on Procedural Routines for Electronic Device Implantation (ESS-PREDI). Europace 2017; 18:778-84. [PMID: 27226497 DOI: 10.1093/europace/euw127] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 04/14/2016] [Indexed: 11/14/2022] Open
Abstract
The European Snapshot Survey on Procedural Routines for Electronic Device Implantation (ESS-PREDI) was a prospective European survey of consecutive adults who had undergone implantation/surgical revision of a cardiac implantable electronic device (CIED) on chronic antithrombotic therapy (enrolment March-June 2015). The aim of the survey was to investigate perioperative treatment with oral anticoagulants and antiplatelets in CIED implantation or surgical revision and to determine the incidence of complications, including clinically significant pocket haematomas. Information on antithrombotic therapy before and after surgery and bleeding and thromboembolic complications occurring after the intervention was collected at first follow-up. The study population comprised 723 patients (66.7% men, 76.9% aged ≥66 years). Antithrombotic treatment was continued during surgery in 489 (67.6%) patients; 6 (0.8%) had their treatment definitively stopped; 46 (6.4%) were switched to another antithrombotic therapy. Heparin bridging was used in 55 out of 154 (35.8%) patients when interrupting vitamin K antagonist (VKA) treatment. Non-vitamin K oral anticoagulant (NOAC) treatment was interrupted in 88.7% of patients, with heparin bridging in 25.6%, but accounted for only 25.3% of the oral anticoagulants used. A total of 108 complications were observed in 98 patients. No intracranial haemorrhage or embolic events were observed. Chronic NOAC treatment before surgery was associated with lower rates of minor pocket haematoma (1.4%; P= 0.042) vs. dual antiplatelet therapy (13.0%), VKA (11.4%), VKA + antiplatelet (9.2%), or NOAC + antiplatelet (7.7%). Similar results were observed for bleeding complications (P= 0.028). Perioperative management of patients undergoing CIED implantation/surgical revision while on chronic antithrombotic therapy varies, with evidence of a disparity between guideline recommendations and practice patterns in Europe. Haemorrhagic complications were significantly less frequent in patients treated with NOACs. Despite this, the incidence of severe pocket haematomas was low.
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Affiliation(s)
- Jean-Claude Deharo
- Department of Cardiology, University Hospital La Timone, Marseilles, France
| | - Elena Sciaraffia
- Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala, Sweden
| | - Christophe Leclercq
- Department of Cardiology, University Hospital Pontchaillou, CIC-IT 804, INSERM 1099, Rennes, France
| | - Walid Amara
- Department of Cardiology, GHI Le Raincy-Montfermeil, Montfermeil, France
| | - Michael Doering
- Department of Electrophysiology, University Leipzig - Heart Center, Leipzig, Germany
| | | | - Jian Chen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Nicolaus Dagres
- Department of Electrophysiology, University Leipzig - Heart Center, Leipzig, Germany
| | - Heidi Estner
- Department of Cardiology, MedizinischeKlinik I, Ludwig-Maximilians-Universität, Campus Großhadern, Marchioninistrasse 15, München 81377, Germany
| | - Torben B Larsen
- Department of Cardiology, AF Study group, Aalborg University Hospital, Aalborg, Denmark
| | - Jens B Johansen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Tatjana S Potpara
- School of Medicine, Belgrade University, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Alessandro Proclemer
- Division of Cardiology, University Hospital S. Maria della Misericordia, IRCAB Foundation Udine, Udine, Italy
| | - Laurent Pison
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute, Maastricht PO Box 5800, The Netherlands
| | - Caroline Brunet
- Department of Cardiology, University Hospital La Timone, Marseilles, France
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20
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Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non-valvular atrial fibrillation: Executive summary. Eur Heart J 2017; 38:2137-2149. [PMID: 27282612 PMCID: PMC5837231 DOI: 10.1093/eurheartj/ehw058] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In 2013, the European Heart Rhythm Association (EHRA) published a Practical Guide on the use of non-VKA oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) (Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P, European Heart Rhythm A. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-2106). The document received widespread interest, not only from cardiologists but also from neurologists, geriatricians, and general practitioners, as became evident from the distribution of >350 000 copies of its pocket version (the EHRA Key Message Booklet) world-wide. Since 2013, numerous new studies have appeared on different aspects of NOAC therapy in AF patients. Therefore, EHRA updated the Practical Guide, including new information but also providing balanced guiding in the many areas where prospective data are still lacking. The outline of the original guide that addressed 15 clinical scenarios has been preserved, but all chapters have been rewritten. Main changes in the Update comprise a discussion on the definition of 'non-valvular AF' and eligibility for NOAC therapy, inclusion of finalized information on the recently approved edoxaban, tailored dosing information dependent on concomitant drugs, and/or clinical characteristics, an expanded chapter on neurologic scenarios (ischaemic stroke or intracranial haemorrhage under NOAC), an updated anticoagulation card and more specifics on start-up and follow-up issues. There are also many new flow charts, like on appropriate switching between anticoagulants (VKA to NOAC or vice versa), default scenarios for acute management of coronary interventions, step-down schemes for long-term combined antiplatelet-anticoagulant management in coronary heart disease, management of bleeding, and cardioversion under NOAC therapy. The Updated Guide is available in full in EP Europace (Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P, Advisors. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507), while additional resources can be found at the related ESC/EHRA website (www.NOACforAF.eu).
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Affiliation(s)
- Hein Heidbuchel
- Hasselt University and Heart Center, Stadsomvaart 11, Hasselt 3500, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Marco Alings
- Department of Cardiology, Amphia Ziekenhuis, Breda, The Netherlands
| | - Matthias Antz
- Department of Cardiology, Klinikum Oldenburg, Oldenburg, Germany
| | - Hans-Christoph Diener
- Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Werner Hacke
- Department of Neurology, Ruprecht Karls Universität, Heidelberg, Germany
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - A. John Camm
- Clinical Cardiology, St George's University, London, UK
| | - Paulus Kirchhof
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK
- Department of Cardiology and Angiology, University of Münster, Münster, Germany
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21
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Leef GC, Hellkamp AS, Patel MR, Becker RC, Berkowitz SD, Breithardt G, Halperin JL, Hankey GJ, Hacke W, Nessel CC, Singer DE, Fox KAA, Mahaffey KW, Piccini JP. Safety and Efficacy of Rivaroxaban in Patients With Cardiac Implantable Electronic Devices: Observations From the ROCKET AF Trial. J Am Heart Assoc 2017; 6:JAHA.116.004663. [PMID: 28615214 PMCID: PMC5669143 DOI: 10.1161/jaha.116.004663] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although implantation of cardiac implantable electronic devices (CIEDs) in patients receiving warfarin is well studied, limited data are available on the use of oral factor Xa inhibitors in this setting. METHODS AND RESULTS Using data from Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) (n=14 264), we compared baseline characteristics and clinical outcomes in patients with atrial fibrillation randomized to rivaroxaban versus warfarin who did and did not undergo CIED implantation or revision. In this post-hoc, postrandomization, on-treatment analysis, only the first intervention per patient was analyzed. During a median follow-up of 2.2 years, 453 patients (242 rivaroxaban group; 211 warfarin group) underwent de novo CIED implantation (64.2%) or revision procedures (35.8%). Patients who received CIEDs were older, more likely to be male, and more likely to have past myocardial infarction, but had similar stroke risk compared to patients who did not receive CIEDs. Most patients who received a device had study drug interrupted for the procedure and did not receive bridging anticoagulation. During the 30-day postprocedural period, 11 patients (4.55%) in the rivaroxaban group experienced bleeding complications compared with 15 (7.13%) in the warfarin group. Thromboembolic complications occurred in 3 patients (1.26%) in the rivaroxaban group and 1 (0.48%) in the warfarin group. Event rates were too low for formal hypothesis testing. CONCLUSIONS Bleeding and thromboembolic events were low in both rivaroxaban- and warfarin-treated patients. Periprocedural use of oral factor Xa inhibitors in CIED implantation requires further study in prospective, randomized trials. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00403767.
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Affiliation(s)
- George C Leef
- Department of Medicine, Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, CA
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | | | - Jonathan L Halperin
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, New York, NY
| | - Graeme J Hankey
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | | | - Daniel E Singer
- Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Keith A A Fox
- University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, CA
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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22
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Black-Maier E, Kim S, Steinberg BA, Fonarow GC, Freeman JV, Kowey PR, Ansell J, Gersh BJ, Mahaffey KW, Naccarelli G, Hylek EM, Go AS, Peterson ED, Piccini JP. Oral anticoagulation management in patients with atrial fibrillation undergoing cardiac implantable electronic device implantation. Clin Cardiol 2017; 40:746-751. [PMID: 28543401 PMCID: PMC5638096 DOI: 10.1002/clc.22726] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 04/19/2017] [Indexed: 01/22/2023] Open
Abstract
Background Oral anticoagulation (OAC) therapy is associated with increased periprocedural risks after cardiac implantable electronic device (CIED) implantation. Patterns of anticoagulation management involving non–vitamin K antagonist oral anticoagulants (NOACs) have not been characterized. Hypothesis Anticoagulation strategies and outcomes differ by anticoagulant type in patients undergoing CIED implantation. Methods Using the nationwide Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we assessed how atrial fibrillation (AF) patients undergoing CIED implantation were cared for and their subsequent outcomes. Outcomes were compared by oral anticoagulant therapy (none, warfarin, or NOAC) as well as by anticoagulation interruption status. Results Among 9129 AF patients, 416 (5%) underwent CIED implantation during a median follow‐up of 30 months (interquartile range, 24–36). Of these, 60 (14%) had implantation on a NOAC. Relative to warfarin therapy, those on a NOAC were younger (70.5 years [range, 65–77.5 years] vs 77 years [range, 70–82 years]), had less valvular heart disease (15.0% vs 31.3%), higher creatinine clearance (67.3 [range, 59.7–99.0] vs 65.8 [range, 50.0–91.6]), were more likely to have persistent AF (26.7% vs 22.9%), and use concomitant aspirin (51.7% vs 35.2%). OAC therapy was commonly interrupted for CIED in 64% (n = 183 of 284) of warfarin patients and 65% (n = 39 of 60) of NOAC patients. Many interrupted patients received intravenous bridging anticoagulation: 33/183 (18%) interrupted warfarin and 4/39 (10%) interrupted NOAC patients. Thirty‐day periprocedure bleeding and stroke adverse events were infrequent. Conclusions Management of anticoagulation among AF patients undergoing CIED implantation is highly variable, with OAC being interrupted in more than half of both warfarin‐ and NOAC‐treated patients. Bleeding and stroke events were infrequent in both warfarin and NOAC‐treated patients.
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Affiliation(s)
- Eric Black-Maier
- Cardiac Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Sunghee Kim
- Duke Clinical Research Institute, Durham, North Carolina
| | - Benjamin A Steinberg
- Cardiac Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles, Los Angeles, California
| | - James V Freeman
- Department of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Peter R Kowey
- Department of Cardiology, Lankenau Hospital and Medical Research Center, Philadelphia, Pennsylvania
| | - Jack Ansell
- Department of Cardiology, New York University School of Medicine, Lenox Hill Hospital, New York, New York
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Kenneth W Mahaffey
- Department of Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Gerald Naccarelli
- Department of Cardiology, Penn State University School of Medicine, Hershey, Pennsylvania
| | - Elaine M Hylek
- Department of Cardiology, Boston University School of Medicine, Boston, Massachusetts
| | - Alan S Go
- Division of Research, Kaiser Permanente, Oakland, California
| | - Eric D Peterson
- Cardiac Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Jonathan P Piccini
- Cardiac Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
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Raval AN, Cigarroa JE, Chung MK, Diaz-Sandoval LJ, Diercks D, Piccini JP, Jung HS, Washam JB, Welch BG, Zazulia AR, Collins SP. Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e604-e633. [PMID: 28167634 DOI: 10.1161/cir.0000000000000477] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Non-vitamin K oral anticoagulants (NOACs) are now widely used as alternatives to warfarin for stroke prevention in atrial fibrillation and management of venous thromboembolism. In clinical practice, there is still widespread uncertainty on how to manage patients on NOACs who bleed or who are at risk for bleeding. Clinical trial data related to NOAC reversal for bleeding and perioperative management are sparse, and recommendations are largely derived from expert opinion. Knowledge of time of last ingestion of the NOAC and renal function is critical to managing these patients given that laboratory measurement is challenging because of the lack of commercially available assays in the United States. Idarucizumab is available as an antidote to rapidly reverse the effects of dabigatran. At present, there is no specific antidote available in the United States for the oral factor Xa inhibitors. Prothrombin concentrate may be considered in life-threatening bleeding. Healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input.
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Davies RA, Perera NK, Orr Y. Do novel anticoagulant agents increase the risk of perioperative complications during implantable cardiac rhythm device insertion? Interact Cardiovasc Thorac Surg 2016; 24:126-128. [PMID: 27600911 DOI: 10.1093/icvts/ivw282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 07/11/2016] [Accepted: 07/29/2016] [Indexed: 11/12/2022] Open
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was 'In patients requiring an implanted cardiac rhythm device, do novel oral anticoagulant agents lead to increased rates of peri-procedural complications?' Altogether 1228 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The novel oral anticoagulant agents (NOACs) assessed in the included studies were dabigatran (a direct thrombin inhibitor) and rivaroxaban (a Factor Xa inhibitor). Dabigatran was included in all five studies and showed bleeding complication rates of 0-4%. Rivaroxaban was included in one study and had bleeding complication rates of 4%. Warfarin was a comparator agent in three studies and had bleeding complication rates of 4.6-8%. The incidence rate of thromboembolic complications was 0-1% with dabigatran and 0% with rivaroxaban and warfarin in all studies. Based on the available studies, there is no evidence of significantly increased risk of bleeding or thromboembolic events with NOACs compared with warfarin when used at the time of cardiac rhythm device implantation. However, not all patients in the studies were actually receiving the specified NOAC at the time of device implantation, thereby limiting the available evidence.
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Affiliation(s)
- Reece A Davies
- Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, Australia .,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Nisal K Perera
- Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, Australia
| | - Yishay Orr
- Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, Australia
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25
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Essebag V, Healey JS, Ayala-Paredes F, Kalfon E, Coutu B, Nery P, Verma A, Sapp J, Philippon F, Sandhu RK, Coyle D, Eikelboom J, Wells G, Birnie DH. Strategy of continued vs interrupted novel oral anticoagulant at time of device surgery in patients with moderate to high risk of arterial thromboembolic events: The BRUISE CONTROL-2 trial. Am Heart J 2016; 173:102-7. [PMID: 26920602 DOI: 10.1016/j.ahj.2015.12.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/04/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients who require perioperative anticoagulation during cardiac implantable electronic device surgery are at increased risk for bleeding complications. The BRUISE CONTROL trial demonstrated that continuing warfarin was safer than heparin bridging, reducing the incidence of clinically significant pocket hematoma. Novel oral anticoagulants are being increasingly prescribed in place of warfarin. The best perioperative management of these new anticoagulants is unknown. METHODS/DESIGN A randomized controlled trial to investigate whether a strategy of continued vs interrupted novel oral anticoagulant (dabigatran, rivaroxaban, or apixaban) at the time of device surgery, in patients with moderate to high risk of arterial thromboembolic events, reduces the incidence of clinically significant hematoma (defined as a hematoma requiring reoperation and/or resulting in prolongation of hospitalization, and/or requiring interruption of anticoagulation). The secondary outcomes include components of the primary outcome, composite of all other major perioperative bleeding events, thromboembolic events, all-cause mortality, cost-effectiveness, patient quality of life, perioperative pain, and satisfaction. Planned analyses include descriptive statistics of all baseline variables. For the primary outcome, interrupted vs continued novel oral anticoagulant arms will be compared using the χ(2) test. If any clinically significant differences are identified, a logistic regression analysis will be conducted. Quality of life will be assessed using EuroQol-5D, and perioperative pain using a visual analog scale. DISCUSSION BRUISE CONTROL-2 is a randomized trial evaluating the best strategy to manage novel oral anticoagulants at the time of device surgery. We hypothesize that device surgery can be performed safely without interruption of these medications.
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26
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AlTurki A, Proietti R, Birnie DH, Essebag V. Management of antithrombotic therapy during cardiac implantable device surgery. J Arrhythm 2016; 32:163-9. [PMID: 27354859 PMCID: PMC4913137 DOI: 10.1016/j.joa.2015.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/03/2015] [Accepted: 12/08/2015] [Indexed: 01/10/2023] Open
Abstract
Anticoagulants are commonly used drugs that are frequently encountered during device placement. Deciding when to halt or continue the use of anticoagulants is a balance between the risks of thromboembolism versus bleeding. Patients taking warfarin with a high risk of thromboembolism should continue to take their warfarin without interruption during device placement while ensuring their international normalized ratio remains below 3. For patients who are taking warfarin and have low risk of thromboembolism, either interrupted or continued warfarin may be used, with no evidence to clearly support either strategy. There is little evidence to support continuing direct acting oral anticoagulants (DOACs) for device implantation. The timing of halting these medications depends largely on renal function. If bleeding occurs, warfarin׳s anticoagulation effect is reversible with vitamin K and activated prothrombin complex concentrate. There are no DOAC reversal agents currently available, but some are under development. Regarding antiplatelet agents, aspirin alone can be safely continued while clopidogrel alone may also be continued, but with a slightly higher bleeding risk. Dual antiplatelet therapy for bare-metal stent/drug-eluting stent implanted within 4 weeks/6 months, respectively, should be continued due to high risk of stent thrombosis; however, if they are implanted after this period, then clopidogrel can be halted 5 days before the procedure and resumed soon after, while aspirin is continued. If the patient is taking both aspirin and warfarin, aspirin should be halted 5 days prior to the procedure, while warfarin is continued.
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Affiliation(s)
- Ahmed AlTurki
- McGill University Health Center, Montreal, Quebec, Canada
| | - Riccardo Proietti
- McGill University Health Center, Montreal, Quebec, Canada; Cardiology Department, Luigi Sacco Hospital, Milan, Italy
| | - David H Birnie
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Vidal Essebag
- McGill University Health Center, Montreal, Quebec, Canada; Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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Widimský P, Kočka V, Roháč F, Osmančík P. Periprocedural antithrombotic therapy during various types of percutaneous cardiovascular interventions. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 2:131-40. [PMID: 27418971 PMCID: PMC4853825 DOI: 10.1093/ehjcvp/pvv053] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/08/2015] [Indexed: 11/14/2022]
Abstract
Percutaneous catheter-based interventions became a critically important part of treatment in modern cardiology, improving quality of life as well as saving many life. Due to the introduction of foreign materials to the circulation (either temporarily or permanently) and due to a certain damage to the endothelium or endocardium, the risk of thrombotic complications is substantial and thus some degree of antithrombotic therapy is needed during all these procedures. The intensity (dosage, combination, and duration) of periprocedureal antithrombotic treatment largely varies based on the type of procedure, clinical setting, and comorbidities. This manuscript summarizes the current therapeutic approach to prevent clotting (and bleeding) during a large spectrum of interventions: acute and elective coronary interventions, acute stroke interventions and elective carotid stenting, electrophysiology procedures, interventions for structural heart disease, and peripheral arterial interventions.
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Affiliation(s)
- P Widimský
- Cardiocenter, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University Prague, Srobarova 50, 100 34 Prague 10, Czech Republic
| | - V Kočka
- Cardiocenter, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University Prague, Srobarova 50, 100 34 Prague 10, Czech Republic
| | - F Roháč
- Cardiocenter, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University Prague, Srobarova 50, 100 34 Prague 10, Czech Republic
| | - P Osmančík
- Cardiocenter, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University Prague, Srobarova 50, 100 34 Prague 10, Czech Republic
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28
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Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17:1467-507. [PMID: 26324838 DOI: 10.1093/europace/euv309] [Citation(s) in RCA: 793] [Impact Index Per Article: 88.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 02/10/2015] [Indexed: 12/24/2022] Open
Abstract
The current manuscript is an update of the original Practical Guide, published in June 2013[Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-51; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-106]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with non-valvular atrial fibrillation (AF). Both physicians and patients have to learn how to use these drugs effectively and safely in clinical practice. Many unresolved questions on how to optimally use these drugs in specific clinical situations remain. The European Heart Rhythm Association set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group defined what needs to be considered as 'non-valvular AF' and listed 15 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 15 topics are (i) practical start-up and follow-up scheme for patients on NOACs; (ii) how to measure the anticoagulant effect of NOACs; (iii) drug-drug interactions and pharmacokinetics of NOACs; (iv) switching between anticoagulant regimens; (v) ensuring adherence of NOAC intake; (vi) how to deal with dosing errors; (vii) patients with chronic kidney disease; (viii) what to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a risk of bleeding?; (xi) management of bleeding complications; (x) patients undergoing a planned surgical intervention or ablation; (xi) patients undergoing an urgent surgical intervention; (xii) patients with AF and coronary artery disease; (xiii) cardioversion in a NOAC-treated patient; (xiv) patients presenting with acute stroke while on NOACs; and (xv) NOACs vs. VKAs in AF patients with a malignancy. Additional information and downloads of the text and anticoagulation cards in >16 languages can be found on an European Heart Rhythm Association web site (www.NOACforAF.eu).
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Sticherling C, Marin F, Birnie D, Boriani G, Calkins H, Dan GA, Gulizia M, Halvorsen S, Hindricks G, Kuck KH, Moya A, Potpara T, Roldan V, Tilz R, Lip GY, Gorenek B, Indik JH, Kirchhof P, Ma CS, Narasimhan C, Piccini J, Sarkozy A, Shah D, Savelieva I. Antithrombotic management in patients undergoing electrophysiological procedures: a European Heart Rhythm Association (EHRA) position document endorsed by the ESC Working Group Thrombosis, Heart Rhythm Society (HRS), and Asia Pacific Heart Rhythm Society (APHRS). ACTA ACUST UNITED AC 2015; 17:1197-214. [DOI: 10.1093/europace/euv190] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Yang X, Wang Z, Zhang Y, Yin X, Hou Y. The safety and efficacy of antithrombotic therapy in patients undergoing cardiac rhythm device implantation: a meta-analysis. Europace 2015; 17:1076-84. [PMID: 25713013 DOI: 10.1093/europace/euu369] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/27/2014] [Indexed: 11/14/2022] Open
Abstract
AIMS The meta-analysis was to assess the safety and efficacy of periprocedural antithrombotic therapy and to evaluate the risk factors potentially associated with bleeding among patients undergoing cardiac implantable electronic devices implantations. METHODS AND RESULTS A systematic literature search of PubMed, EMBASE, and Cochrane Controlled Trials Register was performed. Anticoagulation and antiplatelet therapies were assessed separately. Uninterrupted anticoagulation was associated with significant lower bleeding risk compared with heparin bridging strategy [odds ratio (OR) = 0.31, 95% confidence interval (CI) 0.18-0.53, and P < 0.0001], but there was no significant difference in thromboembolic risk between these two strategies (OR = 0.82, 95% CI 0.32-2.09, and P = 0.65). The haematoma rate was significantly increased in dual antiplatelet therapy group (OR = 6.84, 95% CI 4.16-11.25, and P < 0.00001), but not in single antiplatelet therapy (OR = 1.52, 95% CI 0.93-2.46, and P = 0.09). Clopidogrel increased the risk of haematoma vs. aspirin (OR = 2.91, 95% CI 1.27-6.69, and P = 0.01). Otherwise, a lower risk of haematoma was observed in pacemaker group vs. cardiac resynchronization therapy and/or implantable cardioverter defibrillator group (OR = 0.64, 95% CI 0.50-0.82, and P = 0.0004). CONCLUSION This meta-analysis suggested that uninterrupted oral anticoagulation seems to be the better strategy, associated with a lower risk of bleeding complications rather than heparin bridging, and dual antiplatelet therapy carried a significant risk of bleeding whereas single antiplatelet therapy was relatively safe among patients undergoing cardiac implantable electronic devices implantations. Meanwhile, cardiac resynchronization therapy and/or implantable cardioverter defibrillator implantations increase the bleeding.
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Affiliation(s)
- Xiaowei Yang
- Qianfoshan Hospital of Shandong University, Jinan City, Shandong, People's Republic of China Department of Clinical Pharmacy (Seven-Year), School of Pharmaceutical Sciences, Shandong University, Jinan City, Shandong, People's Republic of China
| | - Zhongsu Wang
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan City 250014, People's Republic of China
| | - Yong Zhang
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan City 250014, People's Republic of China
| | - Xiangcui Yin
- Department of Science and Education, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan City 250014, People's Republic of China
| | - Yinglong Hou
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan City 250014, People's Republic of China
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SANT'ANNA ROBERTOT, LEIRIA TIAGOL, NASCIMENTO THAIS, SANT'ANNA JOÃORICARDOM, KALIL RENATOAK, LIMA GUSTAVOG, VERMA ATUL, HEALEY JEFFS, BIRNIE DAVIDH, ESSEBAG VIDAL. Meta-Analysis of Continuous Oral Anticoagulants Versus Heparin Bridging in Patients Undergoing CIED Surgery: Reappraisal after the BRUISE Study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 38:417-23. [DOI: 10.1111/pace.12557] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/02/2014] [Accepted: 11/13/2014] [Indexed: 01/22/2023]
Affiliation(s)
| | - TIAGO L. LEIRIA
- Instituto de Cardiologia do Rio Grande do Sul; Porto Alegre Brazil
| | | | | | | | - GUSTAVO G. LIMA
- Instituto de Cardiologia do Rio Grande do Sul; Porto Alegre Brazil
| | - ATUL VERMA
- Southlake Regional Health Centre; Newmarket Canada
| | | | | | - VIDAL ESSEBAG
- McGill University Health Centre; Montréal Canada
- Hôpital Sacré-Coeur de Montréal; Montréal Canada
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Krothapalli S, Bhave PD. My Patient Taking A Novel Oral Anticoagulant Needs Surgery, Device Implantation, Or Ablation. J Atr Fibrillation 2014; 7:1145. [PMID: 27957125 DOI: 10.4022/jafib.1145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 10/03/2014] [Accepted: 10/14/2014] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation (AF) is a highly prevalent chronic condition and a growing number of patients are on chronic anticoagulation therapy with novel oral anticoagulant (NOAC) agents: dabigatran, rivaroxaban, and apixaban. Many of these patients are expected to require invasive procedures. There is no clear consensus regarding the peri-procedural management of patients using NOACs, as to how to minimize both bleeding risk and thromboembolism risk. This review of the current available literature is designed to help formulate peri-procedural anticoagulation strategies for patients with AF taking NOACs who are being considered for catheter ablation, device implant, or other surgery. To help frame the discussion, we offer 3 case vignettes that we will revisit to at the end of the review of the existing literature. Case 1: A 62 year-old female with hypertension, diabetes, and symptomatic paroxysmal AF who is prescribed dabigatran for thromboembolism prevention. She has failed attempts at maintaining sinus rhythm with antiarrhythmic drugs. She is now being considered for catheter ablation of AF. Case 2: A 76 year-old male with hypertension, diabetes, prior stroke, and ischemic cardiomyopathy who has persistent drug-refractory AF. He is maintained on chronic anticoagulation with dabigatran for thromboembolism prevention. He has an implantable cardioverter-defibrillator (ICD) which requires a generator change. Case 3: A 58 year-old male with hypertension and paroxysmal AF who takes rivaroxaban for thromboembolic prophylaxis and is being considered for a knee replacement surgery.
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Affiliation(s)
- David H Birnie
- From the University of Ottawa Heart Institute, Ottawa, ON, Canada (D.H.B.); Population Health Research Institute, Hamilton, ON, Canada (J.S.H.); and McGill University Health Center and Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada (V.E.).
| | - Jeff S Healey
- From the University of Ottawa Heart Institute, Ottawa, ON, Canada (D.H.B.); Population Health Research Institute, Hamilton, ON, Canada (J.S.H.); and McGill University Health Center and Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada (V.E.)
| | - Vidal Essebag
- From the University of Ottawa Heart Institute, Ottawa, ON, Canada (D.H.B.); Population Health Research Institute, Hamilton, ON, Canada (J.S.H.); and McGill University Health Center and Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada (V.E.)
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KAHWASH RAMI, DAOUD EMILEG. Just Because You Can, Does That Mean You Should? J Cardiovasc Electrophysiol 2013; 24:1130-1. [DOI: 10.1111/jce.12216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- RAMI KAHWASH
- Ross Heart Hospital, Wexner Medical Center; the Ohio State University; Columbus Ohio USA
| | - EMILE G. DAOUD
- Ross Heart Hospital, Wexner Medical Center; the Ohio State University; Columbus Ohio USA
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