title: Dual antiplatelet therapy and heparin "bridging" significantly increase the risk of bleeding complications after pacemaker or implantable cardioverter-defibrillator device implantation.
abstract: OBJECTIVE
  This study was designed to assess the risk of significant bleeding complications in patients receiving antiplatelet or anticoagulation medications at the time of implantable cardioverter-defibrillator (ICD) device implantation.
  
  
  BACKGROUND
  Periprocedural management of antiplatelet or anticoagulation therapy at the time of device implantation remains controversial.
  
  
  METHODS
  We performed a retrospective chart review of bleeding complications in all patients undergoing ICD or pacemaker implantation from August 2004 to August 2007. Aspirin or clopidogrel use was defined as taken within 5 days of the procedure. A significant bleeding complication was defined as need for pocket exploration or blood transfusion; hematoma requiring pressure dressing or change in anticoagulation therapy; or prolonged hospitalization.
  
  
  RESULTS
  Of the 1,388 device implantations, 71 had bleeding complications (5.1%). Compared with controls not taking antiplatelet agents (n = 255), the combination of aspirin and clopidogrel (n = 139) significantly increased bleeding risk (7.2% vs. 1.6%; p = 0.004). In patients taking aspirin alone (n = 536), bleeding risk was marginally higher than it was for patients taking no antiplatelet agents (3.9% vs. 1.6%, p = 0.078). The use of periprocedural heparin (n = 154) markedly increased risk of bleeding when compared with holding warfarin until the international normalized ratio (INR) was normal (n = 258; 14.3% vs. 4.3%; p < 0.001) and compared with patients receiving no anticoagulation therapy (14.3% vs.1.6%; p < 0.0001). There was no statistical difference in bleeding risk between patients continued on warfarin with an INR > or =1.5 (n = 46) and patients who had warfarin withheld until the INR was normal (n = 258; 6.5% vs. 4.3%; p = 0.50).
  
  
  CONCLUSIONS
  Dual antiplatelet therapy and periprocedural heparin significantly increase the risk of bleeding complications at the time of pacemaker or ICD implantation.
authors.affiliation: Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Christine
authors.initials: C
authors.lastname: Tompkins
authors.forename: Alan
authors.initials: A
authors.lastname: Cheng
authors.forename: Darshan
authors.initials: D
authors.lastname: Dalal
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Brinker
authors.forename: Charles T
authors.initials: CT
authors.lastname: Leng
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Marine
authors.forename: Saman
authors.initials: S
authors.lastname: Nazarian
authors.forename: David D
authors.initials: DD
authors.lastname: Spragg
authors.forename: Sunil
authors.initials: S
authors.lastname: Sinha
authors.forename: Henry
authors.initials: H
authors.lastname: Halperin
authors.forename: Gordon F
authors.initials: GF
authors.lastname: Tomaselli
authors.forename: Ronald D
authors.initials: RD
authors.lastname: Berger
authors.forename: Hugh
authors.initials: H
authors.lastname: Calkins
authors.forename: Charles A
authors.initials: CA
authors.lastname: Henrikson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use; D016022:Case-Control Studies; D000077144:Clopidogrel; D016001:Confidence Intervals; D017147:Defibrillators, Implantable; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006493:Heparin / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010138:Pacemaker, Artificial; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects* / Q000627:therapeutic use; D011182:Postoperative Care / Q000009:adverse effects / Q000379:methods; D019106:Postoperative Hemorrhage / Q000453:epidemiology / Q000209:etiology*; D015995:Prevalence; D012016:Reference Values; D012189:Retrospective Studies; D018570:Risk Assessment; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives / Q000627:therapeutic use; D014859:Warfarin / Q000009:adverse effects / Q000627:therapeutic use
chemical_list: D010975:Platelet Aggregation Inhibitors; D014859:Warfarin; D006493:Heparin; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin