Can medication be administered before a cardiac pacemaker procedure?

Medication Administration Before Cardiac Pacemaker Implantation

Continue oral anti-arrhythmic drugs and anticoagulation through the pacemaker procedure without interruption, as this approach reduces complications and hospital stay while maintaining safety. 1

Anti-Arrhythmic Medications

Continuation of all oral anti-arrhythmic drugs before pacemaker surgery is strongly recommended (Class I recommendation). 1 This includes:

• Beta-blockers: Must be continued and should be administered for at least 24 hours before any cardiac procedure to reduce arrhythmia incidence 1
• Amiodarone: Should be continued without interruption 1
• Other anti-arrhythmic agents: Maintain through the procedure 1

The European Heart Journal guidelines explicitly state that continuation of these medications reduces perioperative arrhythmias and improves outcomes 1.

Anticoagulation Management

For patients on warfarin with high thromboembolic risk, maintain therapeutic anticoagulation (INR 2.0 ± 0.3) through the pacemaker implantation without bridging to heparin. 2, 3

Evidence Supporting Uninterrupted Anticoagulation:

• Randomized trial data shows uninterrupted warfarin is as safe as heparin bridging for pocket hematoma risk (8% vs 7.8%, p=1.00) 2
• Hospital stay is significantly shorter with continued warfarin: median 2 days versus 5 days with heparin bridging (p<0.001) 2
• The FinPAC multicenter randomized trial (N=213) demonstrated non-inferiority of uninterrupted warfarin with pocket hematoma rates of 33% versus 40% with interrupted therapy (HR 0.86, p=0.001 for non-inferiority) 3
• One stroke occurred in the interrupted anticoagulation group versus zero in the uninterrupted group 3

Specific Anticoagulation Recommendations:

• Target INR of 2.0 ± 0.3 on procedure day 2
• Do NOT bridge to heparin unless patient cannot maintain therapeutic oral anticoagulation 2
• Avoid stopping warfarin 2 days before as this increases thromboembolic risk without reducing bleeding 3

Medications to Adjust or Avoid

ACE Inhibitors/ARBs:

The safety of continuing these medications perioperatively is uncertain - consider holding on the morning of surgery due to potential hypotension risk, though definitive evidence is lacking 1

Antiplatelet Agents (if applicable):

• Clopidogrel: Should be discontinued at least 24 hours before if possible to reduce bleeding 1
• Aspirin: Can generally be continued at low dose (75-81 mg) 1

Statins:

Never discontinue - continuation is recommended throughout the perioperative period 1

Critical Procedural Considerations

Prophylactic antibiotics are mandatory - administer 1g cefazolin IV immediately before the procedure, which reduces infection risk from 3.28% to 0.63% (p=0.016) 4

For pacemaker-dependent patients, the device should be interrogated and potentially reprogrammed to asynchronous mode during electrocautery use to prevent inhibition 1

Common Pitfalls to Avoid

• Do not routinely bridge warfarin to heparin - this outdated practice increases hospital stay without improving safety 2, 3
• Do not stop anti-arrhythmic medications - this increases perioperative arrhythmia risk 1
• Do not delay pacemaker implantation for temporary pacing in asymptomatic bifascicular block - temporary pacing is rarely required 1
• Do not forget antibiotic prophylaxis - this is the single most important infection prevention measure 4