Patterns of Anticoagulation Use and Cardioembolic Risk After Catheter Ablation for Atrial Fibrillation

Noseworthy, Peter A.; Yao, Xiaoxi; Deshmukh, Abhishek; Houten, Holly Van; Sangaralingham, Lindsey R.; Siontis, Konstantinos C.; Piccini, Jonathan P.; Asirvatham, Samuel J.; Friedman, Paul A.; Packer, Douglas L.; Gersh, Bernard J.; Shah, Nilay D.

doi:10.1161/jaha.115.002597

Cited by 61 publications

(69 citation statements)

References 34 publications

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“…Though this is likely attributed to a decision by the physician or patient to not initiate an OAC, we cannot rule out the possibility that the administrative database did not accurately reflect actual OAC use. These findings, however, correlate with our previous report of high rate of OAC discontinuation of 40% and 60% at 3 and 12 months after AF ablation, which correlated with increased risk of stroke 27. The OLDW contains only privately insured and Medicare Advantage enrollees, so the conclusion may not necessarily be generalizable to Medicaid, Medicare fee‐for‐service, or uninsured populations.…”

Section: Discussionsupporting

confidence: 78%

Ischemic Stroke or Systemic Embolism After Transseptal Ablation of Arrhythmias in Patients With Cardiac Implantable Electronic Devices

Madhavan

Yao

Sangaralingham

et al. 2016

JAHA

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BackgroundIncidental mobile thrombi are commonly found on endovascular leads of cardiac implantable electronic devices (CIEDs). Transseptal puncture for catheter ablation of arrhythmia poses a risk for paradoxical embolism. We examined risk of ischemic stroke, transient ischemic attack (TIA), or systemic embolism after transseptal ablation in patients with and without CIEDs.Methods and ResultsUsing a national administrative claims database, 31 720 patients who underwent a transseptal catheter ablation between January 2004 and September 2014 were identified. Two propensity‐matched cohorts were created by matching demographic variables, administrative variables, Charlson Comorbidity Index, CHA 2 DS 2‐Vasc score, and year and indication for ablation (5533 and 11 300 patients with and without CIEDs). Incidence rates and Cox proportional hazards models were used to estimate risk of ischemic stroke, TIA, or systemic embolism for patients with and without CIEDs. Impact of oral anticoagulation (OAC) use on the endpoint was examined. Over a mean follow‐up of 2.1 years, the incidence of the combined endpoint was 1.9 per 100 person‐years in patients with CIEDs and 1.5 per 100 person‐years in patients without CIEDs (P=0.03). Among patients not on OAC, presence of a cardiac device was associated with an increased risk (hazard ratio [HR], 1.71 [1.24–2.35]; P<0.01), whereas there was no association noted among patients treated with OAC (HR, 0.98 [0.75–1.28]).Conclusion CIEDs are associated with an increased risk of stroke, TIA, or systemic embolism after transseptal ablation, but this risk is attenuated with postablation OAC use. Role of anticoagulation post‐transseptal ablation in patients with CIED warrants further investigation.

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Section: Discussionsupporting

confidence: 78%

Ischemic Stroke or Systemic Embolism After Transseptal Ablation of Arrhythmias in Patients With Cardiac Implantable Electronic Devices

Madhavan

Yao

Sangaralingham

et al. 2016

JAHA

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“…Some of the discontinuation or interruption of anticoagulation might be clinically warranted because of the development of contraindications or need for surgery. Anticoagulation may also be indicated for only a short time after ablation or cardioversion 16, 52. In fact, our recent study that used the same database demonstrated similar treatment heterogeneity in patients undergoing catheter ablation: it may be beneficial for high‐risk patients to continue anticoagulation beyond 3 months after ablation, while low‐risk patients may safely discontinue the medication 52.…”

Section: Discussionmentioning

confidence: 95%

“…Anticoagulation may also be indicated for only a short time after ablation or cardioversion 16, 52. In fact, our recent study that used the same database demonstrated similar treatment heterogeneity in patients undergoing catheter ablation: it may be beneficial for high‐risk patients to continue anticoagulation beyond 3 months after ablation, while low‐risk patients may safely discontinue the medication 52. However, in most cases, the indication for oral anticoagulants is lifelong and time not taking of oral anticoagulants likely reflects a patient's considered decision 53.…”

Section: Discussionmentioning

confidence: 99%

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

Yao

Abraham

Alexander

et al. 2016

JAHA

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BackgroundIn comparison to warfarin, non–vitamin K antagonist oral anticoagulants (NOACs) have the advantages of ease of dosing, fewer drug interactions, and lack of need for ongoing monitoring. We sought to evaluate whether these advantages translate to improved adherence and whether adherence is associated with improved outcomes in patients with atrial fibrillation.Methods and ResultsWe performed a retrospective cohort analysis by using a large US commercial insurance database to identify 64 661 patients with atrial fibrillation who initiated warfarin, dabigatran, rivaroxaban, or apixaban treatment between November 1, 2010, and December 31, 2014. During a median of 1.1 y of follow‐up, 47.5% of NOAC patients had a proportion of days covered of ≥80%, compared with 40.2% in warfarin patients (P<0.001). Patients with CHA 2 DS 2‐VASc (risk based on the presence of congestive heart failure, hypertension age 65–74 y, age ≥75 y, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, sex category) score ≥4 were at increased risk of stroke when they were not taking anticoagulation ≥1 month versus <1 week (1–3 months: hazard ratio [HR] 1.96, 3–6 months: HR 2.64, ≥6 months: HR 3.66; all P<0.001). Patients with CHA 2 DS 2‐VASc score 2 or 3 were at increased risk of stroke when they were not taking anticoagulation ≥6 months (HR 2.73, P<0.001). In these patients with CHA 2 DS 2‐VASc score ≥2, nonadherence was not associated with intracranial hemorrhage. Among patients with CHA 2 DS 2‐VASc score 0 or 1, time not taking anticoagulation was not associated with stroke, but not taking anticoagulation ≥3 months was associated with a significant reduction of bleeding.ConclusionsAdherence to anticoagulation is poor in practice and may be modestly improved with NOACs. Adherence to therapy appears to be most important in patients with CHA 2 DS 2‐VASc score ≥2, whereas the benefits of anticoagulation may not outweigh the harms in patients with CHA 2 DS 2‐VASc score 0 or 1.

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“…Studies in AF have shown benefit in continuing anticoagulation indefinitely in patients having higher CHADS 2 scores. 124 …”

Section: Continuation Of Anticoagulationmentioning

confidence: 99%

Innovative Approaches to Assess the Impact and Steps to Decrease the Neurological Consequences of Ablation

Ponamgi¹,

Yasin²,

Padmanabhan³

et al. 2016

JICRM

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ABSTRACT. Despite continued innovations in catheter design and technique, catheter ablation for atrial fibrillation (AF) is still fraught with a few serious complications-most feared of which is stroke. Although a ''classic'' clinically disabling stroke is less common (about 1%) after AF ablation, many recent studies have identified an increased incidence of asymptomatic ischemic cerebral lesions known as ''silent clinical lesions'' (SCLs) associated with the procedure. As once thought, these new SCLs seen on post-ablation magnetic resonance imaging of the brain were not actually clinically ''silent'' and were shown to have significant clinical and neuropsychiatric effects on these patients in the long term. These SCLs are thought to represent the ''embolic fingerprints'' of the ablation procedure, suggesting involvement and the need for innovation as well as improved safety at multiple levels before, during, and after the procedure. This may require a multimodality approach involving several measures such as having better peri-procedural anticoagulation strategies, using real-time monitoring for markers of neurologic injury, giving meticulous attention to sheath management, using novel energy sources that are less thrombogenic, and finally establishing imaging protocols for timely detection of these lesions post ablation. The current literature is reviewed here to explore such opportunities to improve neurological outcomes of catheter ablation for AF.

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Patterns of Anticoagulation Use and Cardioembolic Risk After Catheter Ablation for Atrial Fibrillation

Cited by 61 publications

References 34 publications

Ischemic Stroke or Systemic Embolism After Transseptal Ablation of Arrhythmias in Patients With Cardiac Implantable Electronic Devices

Ischemic Stroke or Systemic Embolism After Transseptal Ablation of Arrhythmias in Patients With Cardiac Implantable Electronic Devices

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

Innovative Approaches to Assess the Impact and Steps to Decrease the Neurological Consequences of Ablation

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