Should Dual Antiplatelet Therapy (DAPT) be stopped before permanent pacemaker insertion?

Management of Dual Antiplatelet Therapy Before Permanent Pacemaker Insertion

For patients on dual antiplatelet therapy (DAPT) undergoing permanent pacemaker insertion, the P2Y12 inhibitor should be discontinued at least 1 month after coronary stent implantation, while aspirin should be maintained throughout the perioperative period. 1

Perioperative Management Algorithm

Pre-procedural Assessment:

• A multidisciplinary expert team should evaluate patients on DAPT before pacemaker insertion to balance thrombotic and bleeding risks 1
• Assess time since coronary stent implantation, as this determines the safety of P2Y12 inhibitor discontinuation 1

Management Based on Time Since Stent Implantation:

If >1 month since stent implantation:

• Discontinue P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel) before the procedure 1
  • Clopidogrel: discontinue 5 days before procedure 2
  • Ticagrelor: discontinue 3 days before procedure 1
  • Prasugrel: discontinue 7 days before procedure 1
• Continue aspirin (75-100 mg daily) throughout the perioperative period 1

If <1 month since stent implantation:

• Consider postponing the pacemaker implantation if clinically feasible 2
• If procedure cannot be delayed:
  • Maintain aspirin therapy throughout the perioperative period 1, 2
  • Consider bridging strategy with intravenous agents (cangrelor, tirofiban, or eptifibatide) if P2Y12 inhibitor must be discontinued 1
  • Never discontinue both antiplatelet agents simultaneously due to high risk of stent thrombosis 2

Procedural Considerations:

• Use radial approach when possible to minimize bleeding risk 1, 2
• Consider using specialized devices like PlasmaBlade™ to minimize bleeding complications in high-risk patients 3

Post-procedural Management:

• Resume P2Y12 inhibitor therapy as soon as adequate hemostasis is achieved 1, 2
• Continue DAPT for the originally recommended duration based on indication 1

Special Considerations

Patients with High Bleeding Risk:

• Patients on triple therapy (DAPT plus oral anticoagulation) should be considered at high bleeding risk 1
• The duration of triple therapy should be limited to a maximum of 6 months 1

Patients with High Thrombotic Risk:

• Recent stent thrombosis patients should receive prolonged DAPT 1
• Patients with complex PCI or peripheral arterial disease may benefit from extended DAPT 1

Potential Complications and Management

Bleeding Complications:

• Pocket hematoma is the most common complication, occurring in approximately 3-8% of cases 3, 4
• Significant bleeding complications requiring pocket exploration or blood transfusion are rare (1.5-2%) even in patients on antiplatelet therapy 5, 4

Thrombotic Complications:

• Premature discontinuation of both antiplatelet agents has been associated with stent thrombosis, myocardial infarction, and death 6
• The risk of thrombotic events is highest within the first month after stent implantation 1

Common Pitfalls to Avoid

• Discontinuing both antiplatelet agents simultaneously, which significantly increases thrombotic risk 2
• Bridging with heparin unnecessarily, as this has been associated with higher bleeding rates compared to continuing oral anticoagulation 5, 4
• Delaying resumption of P2Y12 inhibitor therapy after adequate hemostasis is achieved 2