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Perioperative management of antithrombotic therapy in patients receiving cardiovascular implantable electronic devices: a network meta-analysis

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Abstract

Purpose

Network meta-analysis (NMA) has advantages including being able to simultaneously compare and rank multiple treatments over traditional meta-analysis. We evaluated by a NMA the optimal antithrombotic strategy during the perioperative period of implantation of cardiovascular implantable electronic devices (CIEDs).

Methods

We performed a network meta-analysis of observational studies (cohort and case-control studies). The eligible studies tested the following antithrombotic therapy during the CIED placement: aspirin, clopidogrel, warfarin, novel oral anticoagulants (NOACs), and heparin bridging.

Results

Thirty-one observational studies with 119 study arms were included (41,174 patients receiving long-term antithrombotic therapy; median age, 72.6 years; 70.1% males; median follow-up, 3.6 years). Aspirin (4.26 [2.88–7.22]), warfarin (3.37 [2.17–5.23]), and clopidogrel (3.30 [1.49–5.88]) reduced the risk of bleeding as compared with heparin bridging, and there was no significance difference between continued NOACs and heparin bridging (0.67 [0.21–2.18]). The comparison of commonly used protocols in the management of anticoagulant therapy revealed that continued warfarin (0.38 [0.20–0.74]), continued NOACs (0.19 [0.04–0.89]), and heparin bridging therapy (0.01 [0.05–0.21]) increased the risk of bleeding as compared that of control, and continued warfarin (3.74 [1.96–7.16]), interrupted warfarin (4.89 [2.20–10.88]), and interrupted NOACs (12.5 [1.25–100]) reduced the risk of bleeding compared with that of heparin bridging.

Conclusions

Among various antithrombotic drugs, aspirin had the lowest bleeding risk, followed by warfarin, clopidogrel and NOACs, and heparin, with the greatest bleeding risk. NOACs therapy appears safe and effective, and interrupted NOACs may be the optimal anticoagulation protocol for use during the perioperative period of CIED implantation.

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Funding Information

This work was funded by the Cultivating Project Grants of Beijing for Highly Talented Men of Medicine (grant number 2014-3-042).

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Author notes

  1. Hua He and Bing-Bing Ke contributed equally to this work.

Authors and Affiliations

  1. Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People’s Republic of China

    Hua He, Bing-Bing Ke, Fu-Sheng Han, Xiaodong Li & Yu-Jie Zeng

  2. Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, 100029, China

    Yan Li

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Fig. S1

Comparison-adjusted funnel plots. Panels A and C show continued antiplatelet drugs and anticoagulants during the perioperative period of CEID placement: 1, aspirin; 2, warfarin; 3, heparin bridging; 4, NOACs; 5, control; 6, clopidogrel. Panels B and D indicate various anticoagulation strategies used during CEID placement: 1, continued warfarin; 2, interrupted warfarin; 3, heparin bridging; 4, continued NOACs; 5, interrupted NOACs; 6, control. The horizontal axis shows the difference of each i-study’s estimated y_iXY from the summary effect for the respective comparison (y_iXY-uXY). The vertical axis presents a measure of dispersion of y_iXY. The red line represents the null hypothesis that the study-specific effect sizes do not differ from the respective comparison-specific pooled effect estimates. The semi-horizontal line is the regression line. Various colors correspond to various comparisons. Control: no treatment arm. (JPEG 432 kb).

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He, H., Ke, BB., Li, Y. et al. Perioperative management of antithrombotic therapy in patients receiving cardiovascular implantable electronic devices: a network meta-analysis. J Interv Card Electrophysiol 50, 65–83 (2017). https://doi.org/10.1007/s10840-017-0280-4

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