Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Health Informatics, University College London, London, United Kingdom.
Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.
JACC Clin Electrophysiol. 2024 Jan;10(1):121-132. doi: 10.1016/j.jacep.2023.08.037. Epub 2023 Oct 25.
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.
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).
This was an observational multicenter study. We included patients on chronic oral anticoagulation undergoing CIED surgery. Patients were matched using propensity scoring.
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.
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.
在心脏植入式电子设备 (CIED) 手术时，比较维生素 K 拮抗剂 (VKA) 和直接口服抗凝剂 (DOAC) 的数据很少。此外，DOAC 的最佳管理（中断与继续）仍有待确定。
本研究旨在比较根据抗凝类型（DOAC 与 VKA）和方案（中断与不停用），比较设备相关出血和血栓事件的发生率。
这是一项观察性多中心研究。我们纳入了正在接受 CIED 手术的长期口服抗凝治疗患者。患者使用倾向评分进行匹配。
我们纳入了 1975 名患者（年龄 73.8 ± 12.4 岁）。在 1326 名接受 DOAC 治疗的患者中，78.2%（n=1039）术前中断治疗，21.8%（n=287）继续治疗。有 649 名患者继续服用 VKA。匹配后的人群包括 861 名患者。持续使用 DOAC 的任何主要出血率（5.2%）高于间断 DOAC（1.7%）和持续 VKA（2.1%）（P=0.03）。间断 DOAC 的围手术期血栓栓塞率为 1.4%，而 DOAC 或 VKA 持续使用则未发生血栓栓塞事件（P=0.04）。多变量分析显示，双联抗血小板治疗、DOAC 持续使用和男性是大出血的独立预测因素。
在这项大型真实世界队列研究中，与 DOAC 中断或 VKA 持续使用相比，CIED 手术患者中 DOAC 持续使用策略与更高的出血风险相关。然而，DOAC 中断与血栓栓塞风险增加相关。只要临床可能，应避免同时使用双联抗血小板治疗。需要采取个性化的方法，最小化 DOAC 中断的策略可能是最好的折衷方案。
