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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e51

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

rate of 0.6% (11 of 1702). 3 A similar RCT has not been done in the DOAC era, given the ease of brief interruption of DOAC therapy; however, observational studies have shown similar results.2 The PAUSE (Perioperative Anticoagulation Use for Surgery Evaluation) cohort study, discussed below, enrolling patients with a mean CHADS2 score of 2.1 (range, 1-6) and CHA2DS2-VASc score of 3.5 (range, 1-9), found a low incidence of thromboembolic events when DOAC was briefly interrupted without bridging.4 This suggests that in patients at low-to-moderate thromboembolic risk, interruption of anticoagulation, without bridging, may provide a low risk of bleeding with an acceptable risk of stroke/TIA. Patients with mechanical valves, and recent stroke/TIA, or other high-risk markers, were not included in most studies and may still benefit from bridging anticoagulation: in these scenarios, management should be individualized. 2.	 Evidence has accrued that periprocedural unfrac-

tionated or low-molecular-weight heparin bridging has been associated with an increased risk of pocket hematoma after pacemaker or ICD procedures.19 BRUISE-CONTROL (Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial) randomized patients with AF (88%) or a mechanical valve with an estimated annual stroke risk of ≥5%, and undergoing elective device surgery, to continued warfarin versus warfarin interruption with bridging anticoagulation. The incidence of clinically significant pocket hematoma was >4 times higher in the bridging group.5 Several other procedures have been performed on uninterrupted anticoagulation.20 Further study is needed to define which procedures, in which patients, can safely be performed with uninterrupted anticoagulation. Lead extraction procedures are generally considered high bleeding risk and therefore should be treated as such (high bleeding risk procedures in Table 18) and warfarin interrupted, with occasional exceptions. 3.	 Two RCTs and several observational studies have

shown little or no difference in the risk of pocket hematoma and thromboembolic events in patients with AF anticoagulated with DOACs and undergoing device surgery.8–10 Therefore, brief interruption of DOAC therapy (low bleeding risk procedures in Table 18 may be preferable for many, while uninterrupted DOAC may be preferred for those at particularly high thromboembolic risk. Lead extraction procedures are generally considered high bleeding risk and therefore should be treated as such (high bleeding risk procedures in Table 18) and DOAC interrupted, with occasional exceptions. 4.	 To achieve the goals of reducing or eliminating

anticoagulant effect at the time of surgery, while also minimizing the time the patient spends without

Figure 15. Flowchart: Management of Periprocedural Anticoagulation in Patients With AF. Colors correspond to Table 2. AF indicates atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 y (doubled), diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism (doubled), vascular disease, age 65 to 74 y, sex category; DOAC, direct oral anticoagulant; ICD, implantable cardioverter-defibrillator; TE, thromboembolism; and TIA, transient ischemic attack.

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