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Antiplatelet therapy, heparin increase risk for bleeding complications after device implantation

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Periprocedural anticoagulation therapy at the time of device implantation remains controversial, but recently published study results confirm previous findings that dual antiplatelet and, specifically, intravenous heparin use around the time of implantation are strong risk factors for bleeding complications.

“Patients at high risk for thromboembolic events should continue warfarin throughout the periprocedural phase, avoiding the need for heparin bridging,” Christine Tompkins, MD, MS, and colleagues from Johns Hopkins Hospital in Baltimore wrote.

They performed a retrospective chart review of bleeding complications among all patients who underwent implantable cardioverter defibrillator (n=832) or pacemaker (n=556) implantation from August 2004 to August 2007. Antiplatelet usage was defined as aspirin or clopidogrel taken within five days of the procedure.

Mean patient age was 65 years; among patients who received ICDs, average left ventricular ejection fraction was 23.7%. Among the 1,388 devices implanted, the researchers determined that 71 were associated with bleeding complications (5.1%), defined as the need for pocket exploration or blood transfusion; hematoma requiring pressure dressing or change in anticoagulation therapy; or prolonged hospital stay.

Data indicated that patients who were taking a combination of aspirin and clopidogrel (n=139) had an increased bleeding risk (7.2% vs. 1.6%; P=.0004) compared with patients who were not taking antiplatelet agents (n=255). Risk was also higher among patients taking aspirin alone (n=536; 3.9% vs. 1.6%; P=.078).

Compared with patients holding warfarin until INR was normal (n=258), those who had received periprocedural heparin (n=154) had a marked increase for bleeding risk (14.3% vs. 4.3%; P<.0001). No statistical differences in bleeding risk was noted between patients who continued on warfarin with an INR of at least 1.5 (n=46) and those who had warfarin withheld until the INR was normal (n=258; 6.5% vs. 4.3%; P=.05).

“Our findings suggest that patients at greatest risk for thromboembolic events off anticoagulation therapy can be safely continued on warfarin rather than transitioning to heparin, whereas patients at low risk should have warfarin held without instituting ‘bridging,’” the researchers wrote.

Tompkins C. J Am Col Cardiol. 2010;55:2376-2382.

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