How should anticoagulation therapy be managed in patients undergoing pacemaker implantation?

Management of Anticoagulation During Pacemaker Implantation

Uninterrupted oral anticoagulation is recommended in patients undergoing pacemaker implantation to prevent peri-procedural thromboembolic events while minimizing bleeding complications. 1

General Approach to Anticoagulation Management

• For patients on warfarin therapy, continuing warfarin throughout the peri-procedural period with a therapeutic INR is safer than interrupting anticoagulation, resulting in fewer thromboembolic events and pocket hematomas 2, 1
• Target INR should be approximately 2.0 (range 1.8-2.5) on the day of the procedure 3
• Continuing oral anticoagulation during device implantation significantly reduces hospital length of stay compared to bridging strategies 1, 3

Risk-Stratified Approach

High Thromboembolic Risk Patients (e.g., mechanical mitral valve, recent stroke, CHA₂DS₂-VASc ≥4)

• Continue warfarin without interruption during pacemaker implantation 1
• For patients on direct oral anticoagulants (DOACs), a DOAC is recommended in preference to vitamin K antagonists (VKAs) when antiplatelet therapy is also required 4
• If warfarin must be interrupted (rare circumstances), bridging with therapeutic-dose low molecular weight heparin (LMWH) or unfractionated heparin (UFH) is recommended 4

Moderate Thromboembolic Risk Patients (e.g., CHA₂DS₂-VASc 2-3)

• Continue warfarin without interruption during the procedure 2
• If interruption is necessary, consider reduced-dose LMWH bridging in patients with renal insufficiency (CrCl <50 ml/min) 5
• Resume anticoagulation as soon as adequate hemostasis is achieved, typically within 24 hours 4

Low Thromboembolic Risk Patients

• Temporary interruption of warfarin without bridging has been associated with higher risk of transient ischemic attacks 1
• Consider continuing warfarin even in lower-risk patients to minimize thromboembolic risk 1

Special Considerations

• For patients with atrial fibrillation undergoing pacemaker implantation, anticoagulation management should follow the patient's CHA₂DS₂-VASc score rather than the perceived rhythm outcome 4
• Patients with transvenous pacing systems and intracardiac left-to-right shunts may require long-term anticoagulation with a VKA 4
• Placement of transvenous pacing systems is not recommended in patients with right-to-left intracardiac shunting unless no other options are available 4

Practical Implementation

• For patients on DOACs, holding the medication for 1 day (2 doses for dabigatran and apixaban; 1 dose for rivaroxaban) before the procedure is generally sufficient for patients with normal renal function 4
• For procedures requiring complete hemostasis in patients with normal renal function, discontinuation of DOACs for ≥48 hours may be necessary 4
• Monitor for pocket hematoma formation, which is more common in patients receiving bridging therapy with heparin compared to those continuing warfarin 1

Common Pitfalls to Avoid

• Avoid bridging with heparin when continuing warfarin is feasible, as bridging is associated with higher rates of pocket hematoma and longer hospital stays 1, 3
• Avoid complete interruption of anticoagulation without bridging in high-risk patients, as this increases thromboembolic risk 1
• Do not rely on perceived success of rhythm control strategies to determine long-term anticoagulation needs; base decisions on the patient's CHA₂DS₂-VASc score 4