Cardiovascular Disease: Cardiovascular Disease |

Perioperative Management of Oral Anticoagulation Prior to CIED Procedures in the Era of BRUISE CONTROL FREE TO VIEW

Calvin Kwong, MD; Thomas Wentzien, DO
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Santa Clara Valley Medical Center, San Jose, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):74A. doi:10.1016/j.chest.2016.08.082
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SESSION TITLE: Cardiovascular Disease

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM

PURPOSE: Many patients requiring implants of Cardiac Implantable Electronic Devices (CIED) are also on oral anticoagulant, warfarin (OAC). Peri-operative management for these patients has evolved from normalizing their anticoagulation to an appropriate level (INR<1.5) to performing CIED procedures while therapeutic on OAC. To assess the safety and impact this new practice has had on our community, we evaluated the outcomes of this new paradigm in peri-operative OAC management at a large public hospital system.

METHODS: Patients on OAC requiring CIED procedures at our institution were reviewed retrospectively from two time periods. The first group, having CIED procedures performed prior to the landmark NEJM publication BRUISE CONTROL, from Sept 2005 to Nov 2008, were labeled PrBC. The second, labeled AfBC, consisted of patients on OAC managed since this publication, from June 2013 to Dec 2015. The primary outcomes recorded were the peri-procedure INR, thromboembolic events, and clinically significant bleeding. Secondary outcomes were to assess the return to therapeutic anticoagulation post-operatively and use of reversal agents as an indicator of the difficulties of normalizing OAC, often leading to procedural delays.

RESULTS: There were a total of 72 patients evaluated, 32 PrBC patients and 40 AfBC patients. Of these, 55% were male (p=0.7), mean age 66 years (p=0.2). Nonvalvular AF was the indication for OAC in 75% of these patients (p=0.09) with a mean CHADS of 2.3 (p=0.1). The predominant CIED procedure was original pacemaker insertion in 58% of patients (p=0.3). There were no significant difference withbaseline INR (p=0.4). The peri-procedure INR differed significantly, 1.4 in PrBC and 1.9 in AfBC (p<.001, 95% CIs [1.35, 1.53] and [1.76, 2.02] respectively). All cases were successful with significant bleeding or thromboembolic events in either group. The PrBC group had significantly higher use of pre-operative reversal agents, predominantly vitamin K, as compared to the AfBC group (0.53 v 0.14, p<.001, 95% CIs [0.36, 0.70] and [0.04, 0.24] respectively). No blood products were used to reverse any of these patients. By 10 days post operation, the AfBC patients were three times more likely to achieve a therapeutic INR (p<.001) with a mean 10 day post-operative INR of 1.8 in the PrBC group and 2.4 in the AfBC group (p<.001, 95% CIs [1.36, 2.20] and [2.20, 2.60] respectively).

CONCLUSIONS: These results support the management of peri-operative OAC for patients requiring CIED procedures while therapeutic on OAC in a community-based hospital setting. Although there were no differences in the surgical outcomes with either group, the AfBC patients were significantly less likely to experience difficulty or delay in proceeding with their case or delaying their post-operative return to therapeutic INR.

CLINICAL IMPLICATIONS: CIED procedures, done without active normalization of OAC, will reduce the inpatient hospital stay and may reduce the perioperative complications by reducing the duration of time that they are sub-therapeutic. The difficulties of perioperative OAC management will also be reduced by removing the need for pre-operative INR normalization, which in turn will decrease the difficulties of returning these patient to a therapeutic INR.

DISCLOSURE: The following authors have nothing to disclose: Calvin Kwong, Thomas Wentzien

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