• Peri-operative procedural planning of anti-platelet and anticoagulant therapy for device patients is required to minimise the risk of both bleeding and stroke

• Warfarin can usually be continued with careful INR monitoring

• DOAC therapy may need to be discontinued for a short duration as per guidance

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Abbreviations

Each year, an estimated 1.25 million pacemakers and 410,000 implantable cardioverter–defibrillators (ICDs) are implanted worldwide. Between 14 and 35% of patients receiving these devices require long-term oral anticoagulation therapy, and their periprocedural treatment presents a dilemma to physicians. This is particularly true for the subset of patients at moderate-to-high risk (≥5% per year) for thromboembolic events. The risk of pocket haematoma is as high using a bridging heparin protocol. Pocket haematoma is associated with increased risk of device related infection. Temporary cessation of anticoagulation may be associated with increased risk of stroke in high risk patients.

Aspirin - continue if indicated

Clopidogrel- continue if indicated

Dual antiplatelet therapy (any combination) – continue if indicated; review with operating consultant if more than 12 months since coronary intervention/ACS

LMWH/Heparin- Stop ≥ 24 hours pre-procedure

Warfarin – Continue, if clinically indicated, aiming for INR 2-2.5

An INR of 2.5-3.5 may be acceptable to selected operators and should be discussed

Check INR 2-5 days pre-procedure and dose accordingly

Warfarin + single-antiplatelet- continue if clinically indicated

Warfarin + DAPT – discuss strategy with operating consultant

DOAC (as per ESC guidance 2018)

*Emergency/urgent device procedures can be performed on DOAC after discussion with operator.

1. Warfarin dosing and testing, as per pre-procedure, to be resumed same day

2. Avoid re-loading Warfarin unless clinically indicated

3. Restart DOAC ≥ 24 hours post-procedure unless clinical concerns

4. Restart prophylactic LMWH/heparin ≥ 24hour post-procedure

5. Avoid high (treatment) dose LMWH/heparin post-procedure unless clinically appropriate. Ideally establish DOAC post-procedure as above or perform on/initiate warfarin to reduce bleeding complications

6. Patient should be counselled to monitor for signs of bleeding at insertion site and to seek medical attention if this occurs.

7. Inform anticoagulant clinic as appropriate.

Airaksinen KE., Korkeila P., Lund J., Ylitalo A., Karjalainen P., Virtanen V., et al. (2013) 'Safety of pacemaker and implantable cardioverter-defibrillator implantation during uninterrupted warfarin treatment--the FinPAC study', Int J Cardiol, 168(4), pp. 3679-82. Available at: https://doi.org/10.1016/j.ijcard.2013.06.022

Birnie DH., Healey JS., Wells GA., Verma A., Tang AS., Krahn AD., et al. (2013) 'Pacemaker or defibrillator surgery without interruption of anticoagulation', N Engl J Med., 368(22). pp. 2084-93. Available at: https://doi.org/10.1056/NEJMoa1302946

Birnie DH., Healey JS., Wells GA., Ayala-Paredes F., Coutu B., Sumner GL., et al. (2018) 'Continued vs. interrupted direct oral anticoagulants at the time of device surgery, in patients with moderate to high risk of arterial thrombo-embolic events (BRUISE CONTROL-2)', Eur Heart J., 39(44), pp. 3973-3979. Available at: https://doi.org/10.1093/eurheartj/ehy413

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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