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DOACs vs Vitamin K Antagonists During Cardiac Rhythm Device Surgery: A Multicenter Propensity-matched Study (JCEP January 2024)
DOACs vs Vitamin K Antagonists During Cardiac Rhythm Device Surgery: A Multicenter Propensity-matched Study


Introduction: There is a paucity of data comparing vitamin-K antagonists (VKAs) to non-vitamin K anticoagulants (NOACs) at the time of cardiac implantable electronic devices (CIEDs) surgery. Furthermore, the best management of NOACs (interruption vs. continuation) is yet to be determined.

Objective: This study aimed to compare the incidence of device-related bleeds and thrombotic events based on anticoagulant type (NOAC vs. VKA) and regimen (interrupted vs. uninterrupted).
Methods: Observational multicentre study. We included patients on chronic oral anticoagulation undergoing CIEDs surgery. Patients were matched using propensity scoring.

Results: We included 1975 patients (age 73.8±12.4). Among 1326 patients on NOAC, this was interrupted pre-surgery in 78.2% (1039) and continued in 21.8% (287). There were 649 patients on continued VKA. The matched population included 861 patients. The rate of any major bleeding was higher with continued NOAC (5.2%) compared to interrupted NOAC (1.7%) and continued VKA (2.1%) - p=0.03. The rate of perioperative thromboembolism was 1.4% with interrupted NOAC, while no thromboembolic events occurred with NOAC or VKA continuation (p=0.04). Use of dual antiplatelet therapy, NOAC continuation and male gender were independent predictor of major bleedings on a multivariable analysis.

Conclusion: In this large real-world cohort, a continued NOAC strategy was associated with a higher bleeding risk compared to NOAC interruption or VKA continuation in patients undergoing CIEDs surgery. However, NOAC interruption was associated with increased thromboembolic risk. Concomitant dual antiplatelet therapy should be avoided whenever clinically possible. A bespoke approach is necessary, with a strategy of minimal NOAC interruption likely to represent the best compromise.

Kalyanam Shivkumar, MD, PhD, FACC

CME Editor
Kenneth A. Ellenbogen, MD, FACC

Kelvin Bush, MD 

Important Dates
Date of Release: January 22, 2024
Term of Approval/Date of CME/MOC Expiration: January 21, 2025

Availability: On-Demand
Expires on Jan 21, 2025
Cost: FREE
Credit Offered:
1 CME Credit
1 ABIM-MOC Point
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