Factors Influencing Management of Direct Oral Anticoagulants in Patients Undergoing Cardiac Implantable Electronic Device Procedures

Purpose:  Existing literature on anticoagulation management in the periprocedural setting suggests that decisions should be individualized to patient and procedure specific risks, yet there are limited studies on this subject (Baron, Kamath, & McBane, 2013; Daniels, 2015). This represents an opportunity for nursing science and leadership to standardize care and improve patient outcomes.

Methods:  To gain more knowledge on how we have been choosing to manage DOACs in the periprocedural setting, we performed a retrospective chart review of all adult patients prescribed DOACs at the time of CIED procedures at our three facilities from January 2012-June 2016. We analyzed frequency data regarding how many days the DOAC was held before and after the procedure, and if they were bridged with heparin. We also collected data on contributing factors such as comorbidities, concurrent medications, calculated CHA2DS2-VASc and HASBLED scores, age, procedure type, facility location, and year to determine if there were any correlations between these factors and DOAC management decisions.

Results:  Our study had a total of 309 qualifying cases. When analyzing for any contributing factors that were correlated with DOAC management utilizing Type 3 GEE analysis, we found the following statistically significant relationships: Subjects on dual antiplatelet therapy had their DOAC held for significantly less days after the procedure; subjects receiving a defibrillator implant had their DOAC held for significantly more days after the procedure; subjects receiving a pacemaker generator change had their DOAC held for significantly less days after the procedure; subjects receiving a defibrillator generator change had their DOAC held for significantly less days after the procedure.

Conclusion:  Our results found that the type of procedure and the use of dual antiplatelet therapy were significantly related to DOAC management decisions in the perioperative period surrounding CIED procedures. Although research has shown that the bleeding risk of the procedure and the patient’s renal function should be taken in to consideration, we did not find a statistically significant correlation with these factors and DOAC management (Heidbuchel et al., 2013). To ensure patient safety in the future, we would recommend that professional societies develop consensus guidelines on how best to manage DOACs in the periprocedural setting to assess for risk factors and to standardize care.