Evaluation of a new standardized protocol for the perioperative management of chronically anticoagulated patients receiving implantable cardiac arrhythmia devices

Heart Rhythm. 2012 Mar;9(3):361-7. doi: 10.1016/j.hrthm.2011.10.010. Epub 2011 Oct 12.

Abstract

Background: Perioperative management of oral anticoagulation (OAC) in patients receiving pacemakers or implantable cardioverter-defibrillators remains an issue of concern.

Objective: We sought to evaluate the safety and the effect on the hospital length of stay of a new standardized protocol for perioperative management of OAC in this setting.

Methods: The new standardized protocol classified patients according to a renewed evaluation of their thromboembolic (TE) risk. Briefly, patients were considered at moderate-to-high TE risk if they had a mechanical valvular prostheses irrespective of type and location or atrial fibrillation associated with a CHADS(2)score of ≥2, mitral stenosis or previous stroke, and underwent device implantation without stopping OAC (OAC continued, n = 129). Complete interruption of OAC before surgery was performed in low-TE-risk patients (OAC interrupted, n = 82). A retrospective cohort of patients managed with a classic heparin-bridging strategy served as a control group, with 62 patients considered at moderate-to-high TE risk according to previous guidelines (receiving pre- and postoperative low-molecular-weight heparin) and 146 considered at low TE risk (receiving only low doses of postoperative low-molecular-weight heparin).

Results: TE events were comparable between the 2 strategies. Patients entering the new standardized protocol had significantly lower rates of pocket hematoma (2.3% for OAC continued vs 17.7% for moderate-to-high TE risk bridging controls, P = .0001, and 0% for OAC interrupted vs 13% for low-TE-risk bridging controls, P <.0001) and shorter hospital stays. A mean of 3.34 hospitalization days per patient were saved with the new standardized protocol, with an estimated cost savings of €850.83 per patient.

Conclusions: Implantation of the new standardized protocol resulted in a significant reduction in bleeding complications and hospital stays, with adequate protection against TE events and significant cost savings.

Publication types

  • Evaluation Study

MeSH terms

  • Administration, Oral
  • Aged
  • Aged, 80 and over
  • Anticoagulants* / administration & dosage
  • Anticoagulants* / adverse effects
  • Cardiac Pacing, Artificial* / economics
  • Cardiac Pacing, Artificial* / methods
  • Cardiac Pacing, Artificial* / standards
  • Clinical Protocols / standards
  • Cost Savings
  • Defibrillators, Implantable
  • Drug Substitution / methods
  • Drug Substitution / standards
  • Female
  • Heparin, Low-Molecular-Weight / administration & dosage
  • Humans
  • International Normalized Ratio
  • Length of Stay
  • Male
  • Middle Aged
  • Monitoring, Physiologic / methods
  • Multivariate Analysis
  • Pacemaker, Artificial
  • Patient Selection
  • Perioperative Care* / methods
  • Perioperative Care* / standards
  • Perioperative Care* / statistics & numerical data
  • Postoperative Hemorrhage* / epidemiology
  • Postoperative Hemorrhage* / etiology
  • Postoperative Hemorrhage* / prevention & control
  • Risk Factors
  • Thromboembolism* / epidemiology
  • Thromboembolism* / etiology
  • Thromboembolism* / prevention & control

Substances

  • Anticoagulants
  • Heparin, Low-Molecular-Weight