Oral anticoagulation after catheter ablation of atrial fibrillation and the associated risk of thromboembolic events and intracranial hemorrhage: A systematic review and meta‐analysis

Abstract

Aims: We sought to examine whether continuing oral anticoagulation (OAC) after catheter ablation (CA) for atrial fibrillation (AF) is associated with improved outcomes. OAC reduces morbidity and mortality in patients with AF. However, the continuation of OAC following the blanking period of CA is controversial due to conflicting published data.Methods: A systematic review of Medline, Cochrane, and Embase was performed for studies comparing patients who were continued on OAC (ON-OAC) vs those in which OAC was discontinued (OFF-OAC). CHA 2 DS 2 VASc score had to be available for the classification of patients into high-or low-risk cohorts (CHA 2 DS 2 VASc ≥ 2 and ≤ 1, respectively). The primary efficacy outcome was thromboembolic events (TE). Intracranial hemorrhage (ICH) was the primary safety outcome.Results: Five studies comprising 3956 patients were included (mean age, 61.1 ± 2.9 years; 72.4% male, CHA 2 DS 2 VASc ≤ 1 50.1%; CHA 2 DS 2 VASc ≥ 2 49.9%). After a mean follow-up of 39.6 ± 11.7 months, OAC-continuation was associated with a significant decrease in risk of TE in the high-risk cohort (CHA 2 DS 2 VASc ≥ 2) (risk ratio [RR] 0.41, 95% confidence interval [CI] 0.21-0.82, P = .01) with a RR reduction of 59%. ICH was significantly higher in the ON-OAC group (RR, 5.78; 95% CI, 1.33-25.08; P = .02). No significant benefit was observed in the low-risk cohort ON-OAC after the blanking period. Conclusion: Continuation of OAC after CA of AF with CHA 2 DS 2 VASc ≥ 2 is associated with a significant decreased TE risk and a favorable net clinical benefit in Jorge Romero, MD and Roberto C. Cerrud-Rodriguez, MD contributed equally to this work. How to cite this article: Romero J, Cerrud-Rodriguez RC, Diaz JC, et al. Oral anticoagulation after catheter ablation of atrial fibrillation and the associated risk of thromboembolic events and intracranial hemorrhage: A systematic review and meta-analysis.

Knots to untie: anticoagulant and antiarrhythmic therapy after ablation for atrial fibrillation

“… 7 and Romero et al . 8 In the first, anticoagulant therapy was not effective unlike what was shown in the second. A possible explanation of this dissonance is probably to be found in the different basic thromboembolic risk profile of the patients included in the analysis.…”

To continue or stop oral anti‐coagulation in higher‐risk patients after a “successful” AF ablation; that is the question

“…No significant benefit from continued OAC was observed in the low‐risk cohort. Intra cranial hemorrhage was significantly higher in the OAC group (risk ratio 5.78, 95% CI, 1.33‐25.08, P = .02) …”

“…In this issue of the Journal, Romero et al present a systematic review and meta‐analysis of OAC after catheter ablation of AF . They found that OAC continuation was associated with a significant decrease in the risk of thromboembolic events (TE) in the high‐risk cohort (CHA 2 DS 2 VASC ≥ 2; risk ratio 0.41, 95% Confidence Interval [CI] 0.21‐0.82, P = .01).…”

“…The table highlights the key points of the three analyses and gives us some clues as to why there might be different conclusions. Perhaps most importantly, the new study by Romero et al required CHA 2 DS 2 VASC to be reported and stratified their analyses by risk category, whereas Deng et al did not perform a sub‐analysis stratified by CHADS or CHA 2 DS 2 VASC score. Prioetti et al did perform this analysis pooling data from three studies and found a nonsignificant trend in the same direction as Romero's finding, i.e.…”

Continuous rhythm monitoring‐guided anticoagulation after atrial fibrillation ablation

“…Catheter ablation (CA) for AF has steadily advanced over the past two decades, with improvements in success rates. Although current practice guidelines recommend OAC based on established indices of stroke risk such as the CHA 2 DS 2 ‐VASc score, 1 regardless of the perceived success of ablation, 2 a practice of safely discontinuing OAC following CA in selected populations has been reported in several observational studies 3–5 …”