Management of antithrombotic therapy during cardiac implantable device surgery

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• 作者：Ahmed AlTurki ; MD^a ; Riccardo Proietti ; MD ; PhD^a ; ^b ; David H. Birnie ; MD^c ; Vidal Essebag ; MD ; PhD ; FRCPC ; FACC^a ; ^d ; ^{vidal.essebag@mcgill.ca" class="auth_mail" title="E-mail the corresponding author}
• 关键词：Anticoagulant ; Antiplatelet ; Cardiac implantable device surgery
• 刊名：Journal of Arrhythmia
• 出版年：2016
• 出版时间：June 2016
• 年：2016
• 卷：32
• 期：3
• 页码：163-169
• 全文大小：874 K

文摘

Anticoagulants are commonly used drugs that are frequently encountered during device placement. Deciding when to halt or continue the use of anticoagulants is a balance between the risks of thromboembolism versus bleeding. Patients taking warfarin with a high risk of thromboembolism should continue to take their warfarin without interruption during device placement while ensuring their international normalized ratio remains below 3. For patients who are taking warfarin and have low risk of thromboembolism, either interrupted or continued warfarin may be used, with no evidence to clearly support either strategy. There is little evidence to support continuing direct acting oral anticoagulants (DOACs) for device implantation. The timing of halting these medications depends largely on renal function. If bleeding occurs, warfarin׳s anticoagulation effect is reversible with vitamin K and activated prothrombin complex concentrate. There are no DOAC reversal agents currently available, but some are under development. Regarding antiplatelet agents, aspirin alone can be safely continued while clopidogrel alone may also be continued, but with a slightly higher bleeding risk. Dual antiplatelet therapy for bare-metal stent/drug-eluting stent implanted within 4 weeks/6 months, respectively, should be continued due to high risk of stent thrombosis; however, if they are implanted after this period, then clopidogrel can be halted 5 days before the procedure and resumed soon after, while aspirin is continued. If the patient is taking both aspirin and warfarin, aspirin should be halted 5 days prior to the procedure, while warfarin is continued.