Use of Direct Oral Anticoagulants Following Cardiac Implantable Electronic Device Placement.

Abstract

Background: Small studies have described the safety of uninterrupted direct oral anticoagulant (DOAC) use in atrial fibrillation (AF) patients undergoing elective, cardiac implantable electronic device (CIED) placement. Real-world practice patterns and associated outcomes remain poorly defined.

Objective: Describe DOAC usage trends following uncomplicated, outpatient CIED placement in AF patients and evaluate clinical outcomes based on DOAC status at discharge.

Methods: Using data from the National Cardiovascular Data Registry, AF patients with CHA₂DS₂-VASc ≥ 2 undergoing uncomplicated, outpatient CIED placement from April 2016 to December 2019 were stratified by DOAC prescription at discharge. Short and longer-term temporal trends and post-discharge outcomes were assessed using Centers for Medicare and Medicaid (CMS) claims.

Results: Among 59,169 AF patients with elevated thromboembolic eligible for DOAC therapy who underwent elective, new CIED implant or generator replacement, 32,025 (54.1%) were discharged on a DOAC. Annual rates of DOAC use at discharge increased from 47.0% in 2016 to 62.5% in 2019 (p < 0.0001). Overall, patients discharged on DOAC had higher adjusted rates of pocket hematoma (0.51% vs. 0.33%, p = 0.0007) and lower rates of stroke (2.9% vs. 3.2%, p = 0.05) at 30-days but no significant differences in device infection or need for revision at 30-days or 1-year. Those undergoing new CIED implant had higher rates of pocket hematoma at 30-days (0.53% vs. 0.36%, p = 0.02) and need for device revision at 1-year (1.6% vs. 1.3%, p = 0.04).

Conclusion: In AF patients undergoing CIED implantation, about half were discharged on DOACs, with increasing rates of DOAC resumption immediately following post-CIED implantation over the study period. Those discharged on DOACs had modestly higher rates of pocket hematoma or need for device revision but similar risk of device infection.