Objective: The aim of this study was to compare the risks and benefits of three different strategies used in patients undergoing pacemaker and implantable cardioverter defibrillator (ICD) implantation while on chronic oral warfarin therapy.
Methods: From 1/2004 to 8/2008, 458 consecutive patients (male 65%, mean age 71) on chronic warfarin therapy underwent device related procedure (pacemaker or ICD implantation, generator change or lead revision) at our institution. The indications for anticoagulation were atrial fibrillation, (75%), mechanical valves, (13%), pulmonary emboli (8%) and others (4%). Sixty-six percent of the patients also had concurrent antiplatelet agents. Three different strategies were used to manage peri-procedural anticoagulation at the discretion of clinicians:
A. Continuation of warfarin (n=222);
B. Holding warfarin for 5 days prior to the procedure and bridging with IV heparin or SQ enoxaparin (n=123); and
C. Holding warfarin for 5 days without bridging (n=114).
The end points were:
1. clinically significant hematoma and/or major bleeding,
2. TIA/thromboembolic stroke, and
3. post-procedural length of stay.
The outcomes of strategy A were compared to B and C respectively.
Results: There were no significant differences in age, sex and concurrent use of antiplatelet agents. Patients with continuation of warfarin had a lower incidence of hematoma/bleeding (p=0.004) and a shorter hospital stay (p<0.0001) as compared to the bridging group. Holding warfarin without bridging is associated with a higher incidence of TIA/thromboembolic/stroke (p<0.01). Comparisons between A vs B and A vs C are shown in the table.
Conclusions: The strategy of continuing warfarin therapy during device related procedure is safe and appears to be superior as compared to temporarily holding warfarin with or without bridging therapy. This approach is associated with a shorter post-procedural hospital stay and may have a positive impact on the health care cost.