Follow-up After Ablation
Dr. Piña: If you had to give a recommendation to our audience, let's say that they send a patient to ablation and it is successful. Can they lower the international normalized ratio (INR)? What INR should they keep the patient at? And if not warfarin, can they put the patient on a thrombin inhibitor?
Dr. Calkins: The answer is no. There are no data to show that you can lower the INR. What I would do is, at 3-month follow-up, assess the CHA2DS2-VASc score. If the score is 2 or greater, I would recommend to the patient that he continue anticoagulation indefinitely.
Dr. Piña: With whatever they are on at that point?
Dr. Calkins: With whatever they are on or, if they prefer, one of the novel new drugs. I would encourage them to shift at that point. There are some data showing that the best way to have a very low stroke risk at the time of AF ablation is to do the procedure on continued anticoagulation with warfarin, particularly if they are in AF all of the time. That is the safest thing. There are centers or electrophysiologists who will transition a patient to warfarin before the procedure to get them ready. And then they do the procedure and keep the INR therapeutic. If you have tamponade, you can reverse it. Then at 3 months, you can say, "You are probably sick of warfarin. Let's go back to one of these novel new drugs that are much easier to take and more effective in reducing stroke risk."
Dr. Piña: More expensive, though. Let's not forget that.
Dr. Calkins: Perhaps, but it depends on whether you include the cost of their testing.
Cite this: Treating AF: Reducing Stroke Risk With Ablation - Medscape - Nov 04, 2013.