Oral anticoagulation continuation compared with heparin bridging therapy among high-risk patients undergoing implantation of cardiac rhythm devices: a meta-analysis


‘Bridging’ anticoagulation therapy may be bad for you – implications for cardiac device implantation


To prevent thromboembolic complications, some patients with implantable cardioverter defibrillators and pacemakers as well as those undergoing cardiac resynchronization therapy may need long-term anticoagulation. Yet the incidence of perioperative bleeding events seems to be high when choosing heparin bridging strategies. 

In a new meta-analysis published in Opens external link in new windowThrombosis and Haemostasis, Professor of Cardiology Lei Feng and his team at the Department of Cardiology, First Affiliated Hospital, China Medical University, Heping, Shenyang, Liaoning, China, performed a systematic literature search of PubMed/MEDLINE, Ovid and Elsevier and the Cochrane Library databases, looking for articles comparing continuation of oral anticoagulation with heparin bridging therapy. Their meta-analysis included six trials with a total of 629 high-risk subjects continuing oral anticoagulation and 403 high-risk patients with heparin bridging regimens were included.

The findings revealed that pacemaker implantation is feasible without interruption of oral anticoagulation in high-risk populations and that continuing oral anticoagulation is associated with a better risk-benefit ratio than heparin bridging strategies. Even though no differences in thromboembolic events were found between both treatment groups, the incidence of perioperative bleeding complications was lower when continuing oral anticoagulation. In addition, there was a trend for shorter hospital stays favoring the patients receiving continuous oral anticoagulation. The latter was also more convenient to implement than heparin bridging therapy. The risk reduction was significant: a 71% risk reduction of developing pocket hematoma and an 85% lower chance of suffering from hematoma drainage/revision. The authors concluded that implantation of cardiac rhythm devices without interruption of anticoagulation therapy in high-risk patients may offer the best combination of an acceptable risk of bleeding complications with the lowest risk of thromboembolism compared with heparin bridging strategies.

There are several limitations to this meta-analysis since only one study was a randomized trial, the total number of included patients was relatively small, and the type of cardiac rhythm devices which were implanted in the various trials differed considerably. 

The results - published in "Thrombosis and Haemostasis"  suggest that continuing oral anticoagulation might be a safe alternative to heparin bridging in the above mentioned procedures. This would have important implications for clinical practice.  Further well-designed randomized clinical trials with larger sample sizes are needed to confirm these findings.

Feng L, Yang L, Jian L, et al. Opens external link in new windowOral anticoagulation continuation compared with heparin bridging therapy among high-risk patients undergoing implantation of cardiac rhythm device: a meta-analysis. Thromb Haemost 2013; 109: 1124-1131.

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