Among patients undergoing CIED surgery DOAC continuation associated with higher bleeding risk vs VKA continuation

In a pioneering research endeavor, scientists have provided valuable insights into the optimal anticoagulant strategies for patients undergoing cardiac implantable electronic device (CIED) surgery. The study concluded that the best approach to manage is by minimal direct oral anticoagulation (DOAC) interruption during the cardiac implantable electronic device surgery. 

The study results were published in the journal JACC: Clinical Electrophysiology. 

When it comes to patients undergoing cardiac implantable electronic device (CIED) surgery, there's a lack of comprehensive data comparing the use of vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). Additionally, the optimal management of DOACs, including whether to interrupt or continue their use during surgery, remains an open question. Hence researchers conducted an observational multicenter study to compare the incidence of device-related bleeds and thrombotic events based on the choice of anticoagulant (DOAC vs VKA) and the selected regimen (interrupted vs uninterrupted). 

The study, a collaborative effort conducted at multiple medical centers, was observational in nature. It involved patients already on chronic oral anticoagulation therapy who were scheduled for CIED surgery. To ensure a balanced and fair comparison, the researchers employed propensity scoring to match patients with similar characteristics.

Key Findings:

• The study included a comprehensive cohort of 1,975 patients, with an average age of 73.8 years.
• Among these, 1,326 were receiving DOAC therapy, and of this group, 78.2% (1,039 patients) had their DOAC treatment temporarily interrupted before surgery, while 21.8% (287 patients) continued DOAC therapy.
• Another group of 649 patients were on VKA therapy.
• After meticulous matching, the final study population consisted of 861 patients.
• The results were striking and revealed important differences in outcomes between the various anticoagulation strategies.
• Notably, the incidence of major bleeding events was significantly higher among patients who continued DOAC therapy (5.2%) in comparison to those who had their DOAC therapy temporarily interrupted (1.7%) and those who continued VKA therapy (2.1%).
• On the other hand, the study found that the rate of perioperative thromboembolism was 1.4% in the group of patients with interrupted DOAC therapy, whereas no thromboembolic events were observed in patients who either continued DOAC or VKA therapy.
• The study's multivariable analysis also identified independent predictors of major bleeding, including the utilization of dual antiplatelet therapy, the continuation of DOAC therapy, and male gender.

In light of these significant findings, the study underscores the importance of personalized care and tailored anticoagulation strategies for patients undergoing CIED surgery. The research suggests that, when clinically feasible, the use of concomitant dual antiplatelet therapy should be avoided. The key takeaway from this groundbreaking study is that the optimal approach to managing anticoagulant therapy during CIED surgery may involve minimal interruption of DOAC therapy. However, it's important to acknowledge that further research and clinical trials may be necessary to refine these findings and establish best practices in the field. Ultimately, the study paves the way for improved patient care and better outcomes in the realm of cardiac device surgery. 

Further reading: DOACs vs Vitamin K Antagonists During Cardiac Rhythm Device Surgery: A Multicenter Propensity-Matched Study. JACC Clin Electrophysiol. 2023 Oct 16 [Online ahead of print]. https://doi.org/10.1016/j.jacep.2023.08.037