“As Needed” nonvitamin K antagonist oral anticoagulants for infrequent atrial fibrillation episodes following atrial fibrillation ablation guided by diligent pulse monitoring: A feasibility study

Abstract

Introduction After atrial fibrillation (AF) ablation, oral anticoagulation (OAC) is recommended if stroke risk as assessed by CHA2DS 2‐VASc score is high. However, patients without AF are often reluctant to take daily OAC. We describe outcome using as needed nonvitamin K antagonist (NOACs) guided by pulse monitoring to detect AF following successful ablation. Methods and Results We identified 99 patients (84% male, age 64 ± 8 years), CHA2DS 2‐VASc score greater than or equal to 1 in men and greater than or equal to 2 in women (median 2, range 1‐6), capable of pulse assessment twice daily and no AF on extended monitoring after AF ablation. All patients were instructed to start NOAC if AF >1 hour or recurrent shorter episodes. Duration of NOAC use after restart was typically 2 to 4 weeks. After 30 ± 14 months (total 244 patient‐years), 22 patients (22%) transitioned to daily NOAC because of noncompliance with pulse assessment or patient preference (six patients) or because of suspected or documented AF episode(s) in 16 (16%) patients. Of the remaining 77 (78%), 14 (14%) used NOACs but did not transition back to daily use, most (10 patients) with single use (seven patients) or non‐AF rhythm (three patients) documented. There was only one thromboembolic event (0.4%/yr of follow‐up) in patient without AF and one mild bleeding event (epistaxis). Conclusion The use of as needed NOACs when AF is suspected with pulse monitoring is effective and safe to maintain low risk of stroke and bleeding after successful ablation. Transition back to daily NOAC use should be anticipated in about one quarter of patients.

Continuous rhythm monitoring‐guided anticoagulation after atrial fibrillation ablation

“…The rapid onset of therapeutic anticoagulation also make DOACs more suitable for continuous rhythm‐guided anticoagulation, in the event that AF is detected after OAC has been stopped. This strategy of AF‐triggered “as needed” anticoagulation following successful ablation has been used with success 19 . Our current study results add to this body of evidence supporting OAC discontinuation in selected patients following successful ablation, using shared decision making.…”

An Update on the Use of Wearable Devices in Men’s Health

“…Studies indicate that the Apple Watch and other smartwatch devices have clinically acceptable accuracy for heart rate measurements and had a specificity of 94% and sensitivity of 93% in detecting atrial fibrillation [ 64 65 ]. The use of these devices will allow patients to target when they take medications, such as anticoagulants, only when an irregular pulse is detected [ 66 67 ]. While many devices marketed towards managing cardiovascular disease have passed U.S. Food and Drug Administration (FDA) clearance, none has achieved stringent FDA approval yet [ 55 ].…”

Keeping a finger on the pulse of atrial fibrillation

“…In the current issue of Journal of Cardiac Electrophysiology , Zado et al describe a highly selected and well‐trained cohort of 99 patients who underwent an AF ablation and who resumed oral anticoagulation for a period of time only when twice‐daily self‐pulse assessment or some other method of rhythm detection (ie, smartphone electrocardiography [ECG] monitor or implanted cardiac rhythm management device) suggested recurrent AF for at least an hour. Of these, 22% transitioned to daily oral anticoagulation because of noncompliance, patient preference, or recurrent AF, while the majority (63%) of patients remained off anticoagulation altogether and the remaining 15% resumed anticoagulation for a limited time‐frame in response to an AF episode.…”