title: Evaluation of a new standardized protocol for the perioperative management of chronically anticoagulated patients receiving implantable cardiac arrhythmia devices.
abstract: BACKGROUND
  Perioperative management of oral anticoagulation (OAC) in patients receiving pacemakers or implantable cardioverter-defibrillators remains an issue of concern.
  
  
  OBJECTIVE
  We sought to evaluate the safety and the effect on the hospital length of stay of a new standardized protocol for perioperative management of OAC in this setting.
  
  
  METHODS
  The new standardized protocol classified patients according to a renewed evaluation of their thromboembolic (TE) risk. Briefly, patients were considered at moderate-to-high TE risk if they had a mechanical valvular prostheses irrespective of type and location or atrial fibrillation associated with a CHADS(2)score of ≥2, mitral stenosis or previous stroke, and underwent device implantation without stopping OAC (OAC continued, n = 129). Complete interruption of OAC before surgery was performed in low-TE-risk patients (OAC interrupted, n = 82). A retrospective cohort of patients managed with a classic heparin-bridging strategy served as a control group, with 62 patients considered at moderate-to-high TE risk according to previous guidelines (receiving pre- and postoperative low-molecular-weight heparin) and 146 considered at low TE risk (receiving only low doses of postoperative low-molecular-weight heparin).
  
  
  RESULTS
  TE events were comparable between the 2 strategies. Patients entering the new standardized protocol had significantly lower rates of pocket hematoma (2.3% for OAC continued vs 17.7% for moderate-to-high TE risk bridging controls, P = .0001, and 0% for OAC interrupted vs 13% for low-TE-risk bridging controls, P <.0001) and shorter hospital stays. A mean of 3.34 hospitalization days per patient were saved with the new standardized protocol, with an estimated cost savings of €850.83 per patient.
  
  
  CONCLUSIONS
  Implantation of the new standardized protocol resulted in a significant reduction in bleeding complications and hospital stays, with adequate protection against TE events and significant cost savings.
authors: Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain. cano_osc@gva.es
authors: Oscar
authors: O
authors: Cano
authors: Begoña
authors: B
authors: Muñoz
authors: David
authors: D
authors: Tejada
authors: Joaquín
authors: J
authors: Osca
authors: María-José
authors: MJ
authors: Sancho-Tello
authors: José
authors: J
authors: Olagüe
authors: José E
authors: JE
authors: Castro
authors: Antonio
authors: A
authors: Salvador
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D002304:Cardiac Pacing, Artificial / Q000191:economics / Q000379:methods / Q000592:standards; D002985:Clinical Protocols / Q000592:standards; D017046:Cost Savings; D017147:Defibrillators, Implantable; D057915:Drug Substitution / Q000379:methods / Q000592:standards; D005260:Female; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage; D006801:Humans; D019934:International Normalized Ratio; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D015999:Multivariate Analysis; D010138:Pacemaker, Artificial; D018579:Patient Selection; D019990:Perioperative Care / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D019106:Postoperative Hemorrhage / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D012307:Risk Factors; D013923:Thromboembolism / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight