What anticoagulation options are available for patients with permanent pacemakers?

Anticoagulation Options for Patients with Permanent Pacemakers

For patients with permanent pacemakers who require anticoagulation, direct oral anticoagulants (DOACs) are recommended over warfarin unless the patient has moderate-to-severe mitral stenosis or a mechanical heart valve. 1

Risk Assessment and Anticoagulation Decision-Making

• The need for anticoagulation in patients with pacemakers should be determined by the underlying condition requiring anticoagulation (most commonly atrial fibrillation), not the presence of the pacemaker itself 1
• For patients with atrial fibrillation, the CHA₂DS₂-VASc score should be used to assess stroke risk and guide anticoagulation decisions 1
• Anticoagulation is recommended for men with a CHA₂DS₂-VASc score ≥2 or women with a score ≥3 1

Specific Anticoagulation Options

For Most Patients (without mechanical valves or moderate-to-severe mitral stenosis):

• First-line therapy: DOACs (Class I, Level of Evidence: A) 1

  • Apixaban 5 mg twice daily (or 2.5 mg twice daily in selected patients) 1
  • Dabigatran 150 mg twice daily (or 110 mg twice daily in selected patients) 1
  • Rivaroxaban 20 mg once daily (or 15 mg once daily in selected patients) 1
  • Edoxaban 60 mg once daily (or 30 mg once daily in selected patients) 1

• Alternative: Warfarin (Class I, Level of Evidence: A) 1

  • Target INR 2.0-3.0 1, 2
  • INR should be monitored at least weekly during initiation and at least monthly when stable 1

Special Populations:

• Patients with mechanical heart valves: Warfarin is the only recommended option (Class I, Level of Evidence: B) 1, 2

  • Target INR varies by valve type and position:
    • St. Jude Medical bileaflet valve in aortic position: INR 2.0-3.0 2
    • Tilting disk valves and bileaflet valves in mitral position: INR 2.5-3.5 2
    • Caged ball or caged disk valves: INR 2.5-3.5 plus aspirin 75-100 mg/day 2

• Patients with moderate-to-severe mitral stenosis: Warfarin is recommended (Class I, Level of Evidence: B) 1

• Patients with bioprosthetic valves: 2

  • Warfarin with target INR 2.0-3.0 recommended for valves in mitral position
  • Warfarin suggested for valves in aortic position for first 3 months after insertion

Comparative Effectiveness and Safety

• DOACs as a class have demonstrated superior or non-inferior efficacy compared to warfarin for stroke prevention 3, 4
• DOACs are associated with significantly lower risk of intracranial hemorrhage compared to warfarin (HR 0.45,95% CI 0.37-0.56) 3
• Bleeding risk profiles differ among DOACs: 4
  • Apixaban and dabigatran have lower bleeding risk than rivaroxaban
  • Apixaban has the most favorable overall safety profile

Special Considerations for Patients with Pacemakers

• For patients requiring both anticoagulation and antiplatelet therapy (e.g., after PCI): 1

  • Double therapy (DOAC plus P2Y12 inhibitor) is preferred over triple therapy for most patients after hospital discharge
  • Triple therapy (adding aspirin) should be limited to short duration (e.g., 1 month) only in patients at high thrombotic and low bleeding risk

• Renal function should be evaluated before initiating a DOAC and at least annually thereafter, as dose adjustments may be required 1

• For patients requiring procedures: 5

  • Idarucizumab is available for urgent reversal of dabigatran
  • Andexanet alfa is available for reversal of factor Xa inhibitors (apixaban, rivaroxaban, edoxaban)

Treatment Persistence Considerations

• Treatment persistence varies among anticoagulants: 4
  • Highest for apixaban (82%)
  • Lowest for dabigatran and warfarin (64%)
  • This may be an important consideration for long-term therapy in patients with permanent pacemakers