Continuing warfarin therapy superior to bridging, cessation in device surgery
MedWire News: Continuing warfarin anticoagulation during pacemaker or defibrillator implantation in moderate to high thromboembolic risk patients is better tolerated compared with bridging therapy or temporary discontinuation of anticoagulation, US researchers report.
Dennis Zhu (University of Minnesota, Minneapolis) and team explain: “Because of concerns about excessive bleeding and potential associated complications, many clinicians temporarily hold warfarin therapy with or without bridging therapy with heparin or enoxaparin in patients preparing to undergo device implantation.
“While temporarily holding warfarin with or without bridging therapy is common and accepted practice in many cases, our study shows that continuing warfarin bridging therapy is in fact more beneficial to these patients from a safety and cost stand point.”
Similar studies, previously reported by MedWire News, have already shown the benefits of continuing warfarin therapy during catheter ablation of atrial fibrillation with regard to stroke risk reduction.
For the current retrospective study, Zhu et al assessed the outcomes of 459 patients on chronic warfarin therapy. These patients underwent pacemaker or defibrillator implantation between April 2004 and September 2008, and received one of three peri-operative anticoagulation methods: continuation of warfarin (n=222), temporary warfarin cessation with heparin bridging (n=123), or temporary warfarin cessation without bridging (n=114).
All groups were matched for age, gender, and thromboembolism risk.
The study, published in the journal Heart Rhythm, reported a lower incidence of pocket hematomas among patients who continued taking warfarin compared with those who received heparin bridging or had anticoagulation withheld, at 0.45%, 5.7%, and 1.75%, respectively (p=0.004).
Transient ischemic attacks (TIA) were significantly more common in patients who had warfarin temporarily withheld without bridging compared with those who received bridging therapy, at 3.5% versus 0.8%, respectively (p=0.01). TIAs did not occur when warfarin was continued, however.
Further results showed longer hospital stays for patients on bridging therapy compared with those continuing on warfarin, but no difference between patients continuing warfarin and those whose warfarin was temporarily withheld.
“This finding is to be expected, as a patient on bridging therapy with intravenous heparin must be kept in the hospital until INR reaches the therapeutic range,” Zhu and team explain.
They conclude “Implantation of pacemakers and defibrillators in patients on continued warfarin therapy with therapeutic INR appears to be safe and cost effective compared to bridging therapy or temporarily withholding of anticoagulation. These findings need to be confirmed by multicenter, prospective, randomized controlled studies.”
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010
By Lauretta Ihonor