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

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.