From the Guidelines
Most patients with cardiac pacemakers do not need to be on therapeutic anticoagulation solely because of the device itself. However, anticoagulation may be necessary if you have other cardiac conditions that independently warrant it, such as atrial fibrillation, mechanical heart valves, or a history of venous thromboembolism. Immediately after pacemaker implantation, patients are typically prescribed only aspirin or no anticoagulation at all, unless they have pre-existing conditions requiring stronger blood thinners. The pacemaker leads that are placed in the heart become endothelialized (covered with a layer of cells) within a few weeks after implantation, which significantly reduces the risk of clot formation on the leads.
Key Considerations
- The decision to use anticoagulation should be individualized based on your specific cardiac risk factors and discussed with your cardiologist 1.
- If you are already on anticoagulation for another condition, your doctor will provide guidance on how to manage these medications around the time of pacemaker implantation, typically with only a brief interruption if necessary 1.
- For patients at higher risk of thromboembolism, bridging with UFH or LMWH is a common practice, although data for LMWH are limited 1.
- The 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation recommends individualized anticoagulant therapy based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or permanent 1.
Specific Scenarios
- For pediatric patients who need pacing systems, depending on the types of leads and number of leads to be placed, it may be reasonable to consider a nontransvenous system in smaller children to avoid venous thrombosis 1.
- In patients with a transvenous pacing system and an intracardiac left-to-right shunt, long-term anticoagulation with a VKA may be considered 1.
- For patients with AF who have a CHA2DS-VASc score of 2 or greater in men or 3 or greater in women and who have end-stage chronic kidney disease or are on dialysis, it might be reasonable to prescribe warfarin or apixaban for oral anticoagulation 1.
From the Research
Therapeutic Anticoagulation for Cardiac Pacemaker
- The need for therapeutic anticoagulation in patients with cardiac pacemakers depends on the individual's risk of thromboembolic events, as noted in studies 2, 3.
- Patients with atrial fibrillation, a common condition in those with permanent pacemakers, are at high risk for thromboembolic stroke and may require anticoagulation therapy, as discussed in 3.
- The management of anticoagulation during pacemaker implantation is crucial, with options including interruption of anticoagulation with bridging therapy or continuation of anticoagulation, as reviewed in 4.
Perioperative Anticoagulation Management
- Perioperative continuation of anticoagulation with warfarin appears to be a safe and effective approach, with a lower risk of pocket hematoma and thromboembolic events, as found in 2, 4.
- Bridging anticoagulation with heparin is associated with a higher risk of bleeding, as reported in 4.
- Direct oral anticoagulants may be considered as an alternative to warfarin in some patients, but their use in patients with mechanical heart valves is not recommended, as noted in 5.
Role of Pacemakers in Atrial Fibrillation Management
- Pacemakers play a crucial role in the management of atrial fibrillation, particularly in rate control and rhythm control strategies, as discussed in 6.
- Atrioventricular junction ablation with pacemaker implantation can be an effective therapy for controlling rapid ventricular rate during atrial fibrillation, as mentioned in 6.
- Cardiac resynchronization therapy devices may be beneficial in select patients with chronic atrial fibrillation, as noted in 6.