From the Guidelines
Post DBS battery exchange, patients with atrial fibrillation who are not already on anticoagulation generally do not require routine post-operative anticoagulation specifically for the procedure. The decision to start anticoagulation should be based on the patient's underlying stroke risk factors using tools like the CHA₂DS₂-VASc score, rather than the DBS battery exchange procedure itself. If the patient's score indicates a need for anticoagulation (typically ≥2 for men or ≥3 for women), medications such as apixaban (5mg twice daily), rivaroxaban (20mg daily), dabigatran (150mg twice daily), or warfarin (dose adjusted to target INR 2-3) should be considered, as suggested by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. However, if anticoagulation is indicated, it's typically held perioperatively and resumed 24-48 hours after the procedure once hemostasis is assured, as seen in the management of patients with nonvalvular AF with adjusted-dose heparin or LMWH 1. The timing depends on the patient's bleeding risk and stroke risk, and consultation with both neurosurgery and cardiology is advisable to create an individualized plan that addresses both the patient's neurological and cardiac needs. Some key points to consider include:
- The risk of thrombotic events and the severity of the operative and perioperative bleeding risk, as guided by individualized consideration 1
- The duration of interruption and timing of resumption of anticoagulation after the procedure, which should be based on the patient's specific needs and risk factors 1
- The use of bridging anticoagulation with UFH or LMWH for patients at higher risk of thromboembolism, although data for LMWH are limited 1. Overall, the approach should prioritize minimizing the risk of bleeding while also reducing the risk of thromboembolic events, as outlined in the 2014 AHA/ACC/HRS guideline 1.
From the Research
Post-Operative Anticoagulation in Atrial Fibrillation
- The need for post-operative anticoagulation in patients with atrial fibrillation (AFib) who are not on anticoagulation after a DBS battery exchange is a complex issue.
- According to a systematic review with meta-analysis 2, oral anticoagulation (OAC) was associated with a lower risk of thromboembolic events in patients with post-operative atrial fibrillation (POAF) following cardiac surgery, but not in non-cardiac surgery.
- However, the use of OAC was also associated with an increased risk of bleeding in both cardiac and non-cardiac surgery POAF patients 2.
- Another study found that low molecular weight heparin (LMWH) was safe and effective in preventing ischemic stroke in patients with acute AFib 3.
- LMWH has also been shown to be effective in preventing embolic events in patients with AFib in other clinical situations, such as bridging therapy and transesophageal echocardiography-guided cardioversion 4, 5.
Risk Assessment
- The decision to use anticoagulation therapy in patients with AFib should be based on an assessment of their individual risk of thromboembolic events and bleeding 6.
- The CHA2DS2-VASc score is a commonly used scheme for assessing thromboembolic risk in patients with nonvalvular AFib 6.
- Patients with a low risk of stroke (CHA2DS2-VASc score of 0 or 1) may not benefit from anticoagulation therapy 6.
- However, the risk of thromboembolic events in patients with a score of 1 is controversial, and the decision to use anticoagulation therapy should be individualized 6.