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?:abstract
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BACKGROUND Many patients undergoing cardiac device implantation are taking direct oral anticoagulation (DOAC). Continuing DOAC during device implantation may increase periprocedural bleeding risk; however, interrupting DOACs may increase thromboembolic risk. OBJECTIVE To compare the incidence of clinically significant pocket hematoma and thromboembolism in patients who have their DOAC continued or interrupted for cardiac device implantation. METHODS We searched MEDLINE, EMBASE and CENTRAL until December 2019 and included randomized controlled trials (RCTs) and observational studies that compared outcomes after continuing or interrupting DOAC during cardiac device implantation. Independently and in duplicate, reviewers screened titles, abstracts, and full-text of potentially eligible studies. They then evaluated risk of bias and abstracted data. RCT data were pooled using a fixed-effect model. Quality of evidence was assessed using GRADE. RESULTS Two RCTs, representing 763 patients, and 3 observational studies met eligibility criteria. In RCTs, continuing DOAC for device implantation compared to interrupting DOAC resulted in no significant difference in clinically significant pocket hematoma (2.1% vs. 1.8%; RR 1.15; 95%CI 0.44-3.05) or thromboembolism (0.03% vs. 0.03%; RR 1.02; 95%CI 0.06-16.21). Quality of evidence for both outcomes was moderate due to imprecision. Observational studies showed similar results. CONCLUSIONS Continuing DOACs for device implantation results in little to no difference in the incidence of clinically significant pocket hematoma or thromboembolism. Given the ease of stopping and re-starting DOACs, interrupting DOACs may be the preferred strategy for most patients. However, whenever continuous therapeutic anti-coagulation is desired, DOAC continuation should be preferred over bridging with parenteral anticoagulation. This article is protected by copyright. All rights reserved.
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