Comparison of interrupted and uninterrupted anticoagulation strategies for cardiac implantable electronic device insertion: a systematic review and meta-analysis
Authors: Chen B , Phan M , Pasupuleti V , Roman Y M , Hernandez A V 
Published: October 2024

Abstract

Introduction
Up to 35% of patients who are candidates for a cardiac implantable electronic device (CIED) receive chronic anticoagulation. However, guidelines on anticoagulant management in the perioperative period of CIED insertion differ worldwide. It is uncertain whether interrupting or continuing anticoagulation in these settings provides optimal outcomes.

Purpose
To assess the effects of interrupting versus continuing chronic anticoagulation with either warfarin or a direct oral anticoagulant (DOAC) in the perioperative setting of CIED insertion.

Methods
CENTRAL, MEDLINE, Embase, Web of Science, and two trial registries were searched from inception to 26 November 2021. Randomised controlled trials (RCTs) assessing interrupting chronic warfarin or DOAC therapy, with or without heparin bridging, versus continuing anticoagulation in adults undergoing CIED insertion were included. Comparisons were divided into two categories: interrupted versus uninterrupted warfarin and interrupted versus uninterrupted DOAC. Outcomes were expressed as risk ratios (RR) with 95% confidence intervals (95%CI). Inverse variance random-effects models were used for the meta-analyses. Risk of bias (RoB) was assessed using the Cochrane RoB2 tool, and certainty of evidence (CoE) per outcome was assessed with GRADE methods.

Results
Ten RCTs (n=2221) were included: five RCTs (n=1267) used warfarin; four RCTs (n=954) used DOACs. One additional RCT using warfarin was ongoing without any outcome data available. Bleeding events included device-pocket haematoma, haemothorax, cardiac tamponade, and non-tamponade pericardial effusion.
Interrupted versus uninterrupted warfarin:
The evidence is very uncertain on the effect of interrupted warfarin on device-pocket haematoma (RR 1.89, 95%CI 0.85 to 4.20, 5 RCTs, very low CoE) and bleeding events (RR 1.94, 95%CI 0.86 to 4.41, 5 RCTs, very low CoE). Interrupted warfarin may result in little to no difference in thromboembolic events (RR 0.85, 95%CI 0.18 to 4.11, 5 RCTs, low CoE) and ischaemic stroke (RR 1.01, 95%CI 0.11 to 9.61, 2 RCTs, low CoE). Interrupted warfarin may reduce all-cause mortality (RR 0.35, 95%CI 0.04 to 2.93, 3 RCTs, low CoE).
Interrupted versus uninterrupted DOAC:
The evidence is very uncertain on the effect of interrupted DOAC on device-pocket haematoma (RR 1.15, 95%CI 0.58 to 2.28, 4 RCTs, very low CoE) and bleeding events (RR 1.14, 95%CI 0.58 to 2.21, 4 RCTs, very low CoE). Interrupted DOAC may result in little to no difference in thromboembolic events (RR 0.98, 95%CI 0.06 to 15.63, 3 RCT, low CoE) and ischaemic stroke (RR 0.98, 95%CI 0.06 to 15.63, 2 RCTs, low CoE). Interrupted DOAC may reduce all-cause mortality slightly (RR 0.49, 95% CI 0.04 to 5.39, 2 RCTs, low CoE).

Conclusion
Interrupting anticoagulation with either warfarin or DOACs in patients undergoing CIED insertion produced similar outcomes as uninterrupted anticoagulation.Figure 1.Figure 2.