Cost Effectiveness of Continued-Warfarin vs. Heparin-Bridging Therapy During Pacemaker and ICD Surgery | Journal Scan

Study Questions:

What are the economic impacts of using heparin bridging in warfarin-treated patients undergoing surgery for cardiac pacemakers or implantable cardioverter-defibrillators (ICDs)?


The BRUISE CONTROL (Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial) study compared a continued-warfarin and heparin-bridging strategy in 681 atrial fibrillation patients at moderate or high risk for stroke or systemic embolism, who were undergoing surgery for a cardiac pacemaker or ICD implantation. This cost-effectiveness analysis was undertaken from the perspective of the Canadian health care system, including costs related to inpatient hospitalization, anticoagulation use, and need for bridging heparin in the in-patient setting. The primary outcome was the incremental cost or cost saving per hematoma avoided.


As compared to bridging therapy with heparin, a continued warfarin strategy was associated with a markedly reduced incidence of device-pocket hematoma. The overall cost of continued warfarin was significantly lower than in the heparin-bridging cohort ($218 vs. $2,041, p < 0.001), largely driven by lower medication and hospitalization costs. Given that continued warfarin therapy had fewer hematomas, this strategy was dominant.


The authors concluded that continued warfarin therapy during cardiac pacemaker and ICD surgery was both superior at reducing device-pocket hematoma rates and was less costly than a heparin-bridging strategy. The authors estimate approximately $1,800 per-patient-treated savings with the continued warfarin strategy.


This analysis provides a cost-estimate for the strategies of continued warfarin and heparin bridging around the time of cardiac pacemaker and ICD surgery from the BRUISE CONTROL trial. While the main trial results were published in 2013, this study highlights that the continued warfarin strategy is both more clinically beneficial and least costly. A similar trial assessing the risks and benefits of heparin bridging for procedures is currently underway (BRIDGE trial, NCT00786474), and will help to quantify the risks and benefits of a heparin bridging strategy for other procedures and when a continued-warfarin strategy is not an option. In the meantime, electrophysiologists can deliver high-quality and lower cost care by encouraging all atrial fibrillation patients at moderate or high stroke risk who require pacemaker or ICD surgery to utilize a continued-warfarin strategy rather than heparin bridging.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Defibrillators, Implantable, Pacemaker, Artificial, Atrial Fibrillation, Cost Savings, Cost-Benefit Analysis, Warfarin, Anticoagulants, Heparin, Embolism, Hematoma, Hospitalization, Risk Assessment, Stroke

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