Dual Antiplatelet Therapy and Heparin "Bridging" Significantly Increase the Risk of Bleeding Complications After Pacemaker or Implantable Cardioverter-Defibrillator Device Implantation

Christine Tompkins, Alan Cheng, Darshan Dalal, Jeffrey A. Brinker, Charles T. Leng, Joseph E. Marine, Saman Nazarian, David D. Spragg, Sunil Sinha, Henry Halperin, Gordon F. Tomaselli, Ronald D. Berger, Hugh Calkins, Charles A. Henrikson

Research output: Contribution to journalArticle


Objectives: This study was designed to assess the risk of significant bleeding complications in patients receiving antiplatelet or anticoagulation medications at the time of implantable cardioverter-defibrillator (ICD) device implantation. Background: Periprocedural management of antiplatelet or anticoagulation therapy at the time of device implantation remains controversial. Methods: We performed a retrospective chart review of bleeding complications in all patients undergoing ICD or pacemaker implantation from August 2004 to August 2007. Aspirin or clopidogrel use was defined as taken within 5 days of the procedure. A significant bleeding complication was defined as need for pocket exploration or blood transfusion; hematoma requiring pressure dressing or change in anticoagulation therapy; or prolonged hospitalization. Results: Of the 1,388 device implantations, 71 had bleeding complications (5.1%). Compared with controls not taking antiplatelet agents (n = 255), the combination of aspirin and clopidogrel (n = 139) significantly increased bleeding risk (7.2% vs. 1.6%; p = 0.004). In patients taking aspirin alone (n = 536), bleeding risk was marginally higher than it was for patients taking no antiplatelet agents (3.9% vs. 1.6%, p = 0.078). The use of periprocedural heparin (n = 154) markedly increased risk of bleeding when compared with holding warfarin until the international normalized ratio (INR) was normal (n = 258; 14.3% vs. 4.3%; p < 0.001) and compared with patients receiving no anticoagulation therapy (14.3% vs.1.6%; p < 0.0001). There was no statistical difference in bleeding risk between patients continued on warfarin with an INR ≥1.5 (n = 46) and patients who had warfarin withheld until the INR was normal (n = 258; 6.5% vs. 4.3%; p = 0.50). Conclusions: Dual antiplatelet therapy and periprocedural heparin significantly increase the risk of bleeding complications at the time of pacemaker or ICD implantation.

Original languageEnglish (US)
Pages (from-to)2376-2382
Number of pages7
JournalJournal of the American College of Cardiology
Issue number21
StatePublished - May 25 2010



  • anticoagulation
  • antiplatelet
  • complications
  • defibrillator
  • pacemaker

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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