DOACs vs Vitamin K Antagonists During Cardiac Rhythm Device Surgery: A Multicenter Propensity-Matched Study.

BACKGROUND

There is a paucity of data comparing vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs) at the time of cardiac implantable electronic device (CIED) surgery. Furthermore, the best management of DOACs (interruption vs continuation) is yet to be determined.

OBJECTIVES

This study aimed to compare the incidence of device-related bleeds and thrombotic events based on anticoagulant type (DOAC vs VKA) and regimen (interrupted vs uninterrupted).

METHODS

This was an observational multicenter study. We included patients on chronic oral anticoagulation undergoing CIED surgery. Patients were matched using propensity scoring.

RESULTS

We included 1,975 patients (age 73.8 ± 12.4 years). Among 1,326 patients on DOAC, this was interrupted presurgery in 78.2% (n = 1,039) and continued in 21.8% (n = 287). There were 649 patients on continued VKA. The matched population included 861 patients. The rate of any major bleeding was higher with continued DOAC (5.2%) compared to interrupted DOAC (1.7%) and continued VKA (2.1%) (P = 0.03). The rate of perioperative thromboembolism was 1.4% with interrupted DOAC, whereas no thromboembolic events occurred with DOAC or VKA continuation (P = 0.04). The use of dual antiplatelet therapy, DOAC continuation, and male sex were independent predictors of major bleeding on a multivariable analysis.

CONCLUSIONS

In this large real-world cohort, a continued DOAC strategy was associated with a higher bleeding risk compared to DOAC interruption or VKA continuation in patients undergoing CIED surgery. However, DOAC interruption was associated with increased thromboembolic risk. Concomitant dual antiplatelet therapy should be avoided whenever clinically possible. A bespoke approach is necessary, with a strategy of minimal DOAC interruption likely to represent the best compromise.

Informations de copyright

Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Déclaration de conflit d'intérêts

Funding Support and Author Disclosures Dr Creta has received speaker fees from Boston Scientific. Dr Finlay has received research support and speaker fees from Abbott Ltd, Medtronic Ltd, and Biosense Webster; is Chief Medical Officer, Founder, and Shareholder of Echopoint Medical Ltd; is Director, Founder, and Shareholder of Rhythm AI; is Founder and Shareholder of Epicardio Ltd; and has received research funding from National Institutes of HealthR Barts BRC funding. Dr Lambiase has received educational grants from Medtronic and Boston Scientific; and is supported by UCLH Biomedicine National Institute for Health and Care Research and Barts BRC funding. Dr Schilling has had research agreements and has received speaker fees from Abbott, Medtronic, Boston Scientific, and Biosense Webster; and is a shareholder of AI Rhythm. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.