title: No increased bleeding events with continuation of oral anticoagulation therapy for patients undergoing cardiac device procedure.
abstract: BACKGROUND
  Switching warfarin for heparin has been a practice for managing periprocedural anticoagulation in high-risk patients undergoing device-related procedures. We sought to investigate whether continuation of warfarin sodium therapy without heparin bridging is safe and, when it is continued, the optimal international normalized ratio (INR) without increased bleeding risk at time of device-related procedure.
  
  
  RESULTS
  We retrospectively studied 766 consecutive patients taking warfarin long term who underwent device-related procedures. Patients were grouped by treatment: discontinued warfarin (-warfarin, n = 243), no interruption of warfarin (+warfarin, n = 324), and discontinued warfarin with heparin bridging (+heparin, n = 199). The study primary endpoint was systemic bleeding or formation of moderate or severe pocket hematoma within 30 days of the procedure. Thirty-one (4%) patients had bleeding events, including pocket hematoma in 29 patients. The bleeding events occurred more often for +heparin (7.0%) than -warfarin (2.1%) or +warfarin (3.7%, P = 0.029). For +warfarin group, INR of 2.0-2.5 at time of procedure did not increase bleeding risk compared with INR less than 1.5 (3.7% vs 3.4%; P = 0.72), but INR greater than 2.5 increased the bleeding risk (10.0% vs 3.4%; P = 0.029). Concomitant aspirin use with warfarin significantly increased bleeding risk than warfarin alone (5.6% vs 1.4%, P = 0.02). Median length of hospitalization was significantly shorter for +warfarin than +heparin (1 vs 6 days; P < 0.001).
  
  
  CONCLUSIONS
  Continuation of oral anticoagulation therapy with an INR level of <2.5 does not impose increased risk of bleeding for device-related procedures, although precaution is necessary to avoid supratherapeutic anticoagulation levels.
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA.
authors.forename: Hung-Kei
authors.initials: HK
authors.lastname: Li
authors.forename: Frank C
authors.initials: FC
authors.lastname: Chen
authors.forename: Robert F
authors.initials: RF
authors.lastname: Rea
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Asirvatham
authors.forename: Brian D
authors.initials: BD
authors.lastname: Powell
authors.forename: Paul A
authors.initials: PA
authors.lastname: Friedman
authors.forename: Win-Kuang
authors.initials: WK
authors.lastname: Shen
authors.forename: Peter A
authors.initials: PA
authors.lastname: Brady
authors.forename: David J
authors.initials: DJ
authors.lastname: Bradley
authors.forename: Hon-Chi
authors.initials: HC
authors.lastname: Lee
authors.forename: David O
authors.initials: DO
authors.lastname: Hodge
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Slusser
authors.forename: David L
authors.initials: DL
authors.lastname: Hayes
authors.forename: Yong-Mei
authors.initials: YM
authors.lastname: Cha
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects* / Q000627:therapeutic use; D017147:Defibrillators, Implantable; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced*; D006493:Heparin / Q000009:adverse effects* / Q000627:therapeutic use; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D010138:Pacemaker, Artificial; D012189:Retrospective Studies; D012307:Risk Factors; D014859:Warfarin / Q000009:adverse effects* / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin; D006493:Heparin