Perioperative anticoagulation in patients having implantation of a cardiac pacemaker or defibrillator: a systematic review and practical management guide.
BACKGROUND
The perioperative management of anticoagulation in patients who are having implantation of a pacemaker or implantable cardioverter defibrillator (ICD) is a common clinical problem in which best clinical practise is not established.


METHODS
We performed a systematic review of the literature to assess the safety (pocket hematoma risk) and efficacy (thromboembolism risk) of different management strategies. We included studies involving patients who were having pacemaker or ICD implantation whenever a portion of these patients were receiving a coumarin and also assessed pocket hematoma or thromboembolism.


RESULTS
We identified eight studies that assessed two strategies used for perioperative anticoagulation management: interruption of a coumarin and use of bridging anticoagulation with a short-acting heparin; and perioperative continuation of a coumarin. A strategy involving bridging anticoagulation with therapeutic-dose heparin was associated with an incidence of pocket hematoma of 12-20%. A strategy involving perioperative continuation of a coumarin was associated with an incidence of pocket bleeding of 1.9-6.6%. The incidence of thromboembolic events was 0-1%, irrespective of the perioperative anticoagulation strategy used.


CONCLUSIONS
The perioperative anticoagulation management of patients who require pacemaker or ICD implantation is not established but a strategy involving postoperative bridging with intravenous heparin confers a high risk for bleeding whereas perioperative continuation of a coumarin appears to confer a lower risk for bleeding.
Jamula
E
E
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Douketis
J D
JD
Schulman
S
S
D000925:Anticoagulants / Q000627:therapeutic use*; D003374:Coumarins / Q000627:therapeutic use; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D006406:Hematoma / Q000209:etiology / Q000517:prevention & control; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D010138:Pacemaker, Artificial / Q000009:adverse effects*; D019990:Perioperative Care; D017410:Practice Guidelines as Topic; D019919:Prosthesis Implantation / Q000009:adverse effects*; D013923:Thromboembolism / Q000209:etiology / Q000517:prevention & control
D000925:Anticoagulants; D003374:Coumarins; D006493:Heparin; C030123:coumarin