- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT02094157
Tapered Warfarin or Interrupted Warfarin With Heparin Bridging for Pacemaker or Defibrillator Implantation (PACEBRIDGE)
April 1, 2016 updated by: McMaster University
An Open-Label Randomized Control Trial of Pre-Operative Low Molecular Weight Heparin Versus Tapered Warfarin as Bridging Therapy for Patients With Implantation of Pacemaker or Defibrillator
Approximately 2 million patients in North America are currently treated with the blood thinner warfarin.
These patients have every year more than 200,000 invasive procedures, for which warfarin must be stopped to avoid bleeding complication.
To protect the patient against blood clots and stroke while warfarin is stopped, most physicians today order "bridging" with low-molecular-weight heparin (LMWH).
This is another blood thinner and it is injected under the skin during 3 days before the procedure.
For implantation of pacemaker or defibrillator (27,000/year in Canada) the "bridging" routines vary a lot.The common "bridging" treatment with LMWH for 3 days before pacemaker surgery causes bleeding in the "pocket" where the pacemaker is placed in about 5%.
For comparison, patients not on any blood thinners develop this bleeding in 2% after this surgery.
"Pocket bleeding" may require evacuation of the blood collection and may cause infection.
"Pocket bleeding" is thus a fairly common and clinically important but rarely a dangerous bleeding complication.
It is a suitable safety endpoint in a study of "bridging" of blood thinners.
LMWH costs $80-120, for which some patients are not covered.
They have to be taught self-injection technique or have a nurse come to their home.
The main hypothesis is if patients on blood thinners can be managed more conveniently before and after pacemaker surgery, without injections, without increased risk of pocket bleeding.
Study Overview
Status
Terminated
Conditions
Intervention / Treatment
Detailed Description
Patients are recruited from those routinely referred before surgery for adjustment of their blood thinners.
Suitable and consenting patients are randomized to one of the two regimens.
They will either stop warfarin for 5 days and replace it with injections of LMWH for 3 days before pacemaker or implantable cardioverter defibrillator (ICD) surgery.
The other group will have the dose of warfarin reduced to half for 3-6 days before surgery, depending on how thin their blood is.
For all patients the degree of blood thinning is checked the day before surgery.
If the blood is still to thin, the patient is instructed to take by mouth a dose of vitamin K, provided by us, to reduce the effect of warfarin.
After surgery the patients restart warfarin at a double dose for 1 or 2 days to quickly reach the therapeutic effect again.
Staff from the Pacemaker or Defibrillator Clinic, unaware of the treatment allocation, examines the patient for bleeding in the implantation pocket before they leave the hospital, and at routine follow-up after 2-3 weeks and 90 days.
Study Type
Interventional
Enrollment (Actual)
173
Phase
- Phase 3
Contacts and Locations
This section provides the contact details for those conducting the study, and information on where this study is being conducted.
Study Locations
-
-
Ontario
-
Hamilton, Ontario, Canada, L8N 4A6
- St. Joseph's Healthcare
-
Hamilton, Ontario, Canada, L8L 2X2
- Hamilton Health Sciences-General Hospital
-
-
Participation Criteria
Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.
Eligibility Criteria
Ages Eligible for Study
18 years and older (Adult, Older Adult)
Accepts Healthy Volunteers
No
Genders Eligible for Study
All
Description
Inclusion Criteria:
- The patient has been receiving warfarin therapy for at least 1 week and is planned to continue this treatment for at least one month post-procedure
- The patient will have elective implantation or replacement of a pacemaker or ICD
Exclusion Criteria:
- Age <18 years
- Previous stroke
- Stroke risk (CHADS2) score of 0 or 1 in patients with atrial fibrillation as the only indication for anticoagulation
- Creatinine clearance (CrCl) <30 mL/min
- Surgery planned for a Monday or a day after a holiday
- Patient unsuitable for the study as assessed by the investigator (e.g., psychiatric disorder, history of non-compliance)
- Failure to obtain written consent
Study Plan
This section provides details of the study plan, including how the study is designed and what the study is measuring.
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Single
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Active Comparator: Bridged regimen
Bridged regimen Warfarin therapy is stopped for 5 days before surgery and restarted in the evening of surgery at double the usual dose for two days.
Bridging with low-molecular-weight heparin at therapeutic dose is given for 2½ days before surgery.
|
This intervention is assigned to the active control arm - Bridged regimen
Other Names:
|
Experimental: Tapered warfarin regimen
Tapered warfarin regimen Warfarin is given at half the usual maintenance dose for 3-6 days before surgery depending on the INR at the baseline visit.
A double dose is given in the evening of surgery.
No bridging with LMWH is used.
|
This intervention is assigned to the experimental arm - Tapered warfarin regimen
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Pocket hematoma
Time Frame: 1 month
|
Pocket hematoma is defined as palpable swelling of the pacemaker or defibrillator pocket exceeding the size of the generator.
|
1 month
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Major bleeding
Time Frame: 1 month
|
Fatal bleeding OR Symptomatic bleeding in a critical area or organ, such as intracranial, intraspinal, intraocular, retroperitoneal, intraarticular or pericardial, or intramuscular with compartment syndrome OR Bleeding causing a fall in hemoglobin level of 20 g·L-1 (1.24 mmol·L-1) or more, or leading to transfusion of two or more units of whole blood or red cells.
|
1 month
|
Thromboembolism
Time Frame: 1 month
|
Arterial thromboembolism, consisting of one or more of the following: stroke (ischemic or hemorrhagic), transient ischemic attack, systemic embolism to a limb or viscus, thrombosis of a mechanical or native heart valve, or thrombosis of a cardiac chamber.
OR Venous thromboembolism that is symptomatic AND for deep vein thrombosis is verified by ultrasound, venography or computed tomography; for pulmonary embolism is verified by ventilation-perfusion lung scan, spiral computed tomography or pulmonary angiography.
|
1 month
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Preoperative reversal with vitamin K
Time Frame: 1 day
|
Patients with International Normalized Ratio (INR) above 1.7 the day before surgery require correction of the coagulopathy with vitamin K to allow for surgery.
|
1 day
|
Collaborators and Investigators
This is where you will find people and organizations involved with this study.
Sponsor
Publications and helpful links
The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.
Study record dates
These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.
Study Major Dates
Study Start
December 1, 2007
Primary Completion (Actual)
November 1, 2013
Study Completion (Actual)
March 1, 2014
Study Registration Dates
First Submitted
March 19, 2014
First Submitted That Met QC Criteria
March 20, 2014
First Posted (Estimate)
March 21, 2014
Study Record Updates
Last Update Posted (Estimate)
April 5, 2016
Last Update Submitted That Met QC Criteria
April 1, 2016
Last Verified
April 1, 2016
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Pathologic Processes
- Heart Diseases
- Cardiovascular Diseases
- Vascular Diseases
- Embolism and Thrombosis
- Hemorrhage
- Arrhythmias, Cardiac
- Thromboembolism
- Molecular Mechanisms of Pharmacological Action
- Fibrinolytic Agents
- Fibrin Modulating Agents
- Anticoagulants
- Heparin
- Calcium heparin
- Heparin, Low-Molecular-Weight
- Tinzaparin
- Dalteparin
- Warfarin
Other Study ID Numbers
- PB 20080717
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
NO
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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