Risk of Stroke and Recurrence After AF Ablation in Patients With an Initial Event-Free Period of 12 Months

Simon Kochhäuser, M.D.; Pouria Alipour, B.Sc.; Tanjah Haig-Carter, B.Sc.; Kathleen Trought, B.Sc.; Philip Hache, B.Sc.; Yaariv Khaykin, M.D.; Zaev Wulffhart, M.D.; Alfredo Pantano, M.D.; Bernice Tsang, M.D.; David Birnie, M.D.; Atul Verma, M.D.

Disclosures

J Cardiovasc Electrophysiol. 2017;28(3):273-279.

Clinical Implications

The results of our study indicate that patients with an AF/AT-free interval of at least 12 months after AF ablation have a low risk of stroke/TIA and justify further research on the safety of discontinuing OAC after successful AF ablation. Prospective, randomized studies, like the upcoming OCEAN trial (https://clinicaltrials.gov/ct2/show/NCT02168829), that will be including a similar patient population, will be needed to determine whether OAC can be safely stopped postablation or whether the risk of stroke remains high enough to justify long-term OAC continuation.

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Table 1. Patient Characteristics Stratified by AF/AT Recurrence
	All Patients	Recurrence	No Recurrence	P
n (%)	398	55 (13.8%)	343 (86.2%)
Follow-up in days	528.5 (373, 111,3.5)	1,471 (1,007, 1,935)	455 (367, 851)	<0.001
Persistent AF	119 (29.9%)	27 (49.1%)	92 (26.8%)	0.001
Age	60.7 (50.8, 66.8)	62.5 (52, 66.6)	60.1 (50.7, 67)	0.36
Female	98 (24.6%)	14 (25.5%)	84 (24.5%)	0.88
Hypertension	196 (49.2%)	27 (49.1%)	182 (53.1%)	0.58
Diabetes	49 (12.3%)	11 (20%)	38 (11.1%)	0.062
Hx of stroke/TIA	16 (4%)	1 (1.8%)	15 (4.4%)	0.37
Vascular disease	12 (3%)	1 (1.8%)	11 (3.2%)	0.7
Heart failure	29 (7.3%)	4 (7.3%)	25 (7.3%)	1
Hyperlipidemia	172 (43.2%)	20 (36.4%)	152 (44.3%)	0.27
Hx of smoking	56 (14.1%)	7 (12.7%)	49 (14.3%)	0.41
CAD	42 (10.6%)	5 (9.1%)	37 (10.8%)	0.82
CHADS₂-score	0.85 (±0.9)	0.85 (±0.93)	0.85 (±0.9)	0.97
CHA₂DS₂-VASc-score	1.46 (±1.28)	1.53 (±1.32)	1.45 (±1.28)	0.65
AAD discontinued	369 (92.7%)	54 (98.2%)	315 (91.3%)	0.16
OAC discontinued	276 (69.3%)	36 (65.5%)	240 (70%)	0.5
Months to recurrence		25.5 (17, 42)
Number of ablation procedures	1.1 (±0.3)	1.09 (±0.3)	1.15 (±0.4)	0.34

Hx = history; CAD = coronary artery disease; TIA = transient ischemic attack.

Table 2. Distribution of CHADS ₂- and CHA ₂DS ₂-VASc-Scores in the Study Population and Expected Stroke Rates for Each Score Level
	n	Expected Stroke rate (%/year)	AAD Discontinued	OAC Discontinued
CHADS₂
0	166 (41.2%)	1.9%	158 (95.2%)	146 (88%)
1	153 (38.4%)	2.8%	144 (94.1%)	110 (71.9%)
2	57 (14.3%)	4.0%	47 (82.5%)	17 (29.8%)
3	18 (4.5%)	5.9%	17 (94.4%)	3 (16.7%)
4	4 (1%)	8.5%	3 (75%)	0
CHA₂DS₂-VASc
0	108 (27.1%)	0	102 (94.4%)	101 (93.5%)
1	121 (30.4%)	1.3%	114 (94.2%)	98 (81%)
2	84 (21.1%)	2.2%	79 (94%)	53 (63.1%)
3	58 (14.6%)	3.2%	52 (89.7%)	20 (34.5%)
4	20 (5%)	4.0%	16 (80%)	4 (20%)
5	5 (1.3%)	6.7%	4 (80%)	0
6	2 (0.5%)	9.8%	2 (100%)	0

Table 3. Univariate Analysis for AF/AT Recurrence
	Odds Ratio	95% Confidence Interval	P
Persistent AF	2.63	1.47–4.7	0.001
Age	1.012	0.99–1.04	0.39
Female	1.05	0.55–2.03	0.88
Hypertension	0.85	0.48–1.51	0.58
Diabetes	2.01	0.96–4.21	0.066
Hx of Stroke/TIA	0.4	0.05–3.11	0.38
Vascular disease	0.44	0.06–3.47	0.43
Heart failure	1	0.33–2.99	0.997
Hyperlipidemia	0.718	0.4–1.29	0.27
Hx of smoking	0.69	0.29–1.67	0.41
CAD	0.83	0.31–2.21	0.7
AAD discontinued	4.8	0.64–36.02	0.13

Hx = history; CAD = coronary artery disease; TIA = transient ischemic attack.

Table 4. Stratification of Patients According to the CCS 2016, AHA 2014, and ESC 2016 Recommendation for Anticoagulation
CCS 2016 Recommendation	n	AAD Discontinued	OAC Discontinued	Recurrence
OAC	262 (65.8%)	241 (92%)	152 (58%)	36 (13.7%)
ASA	8 (2%)	5 (62.5%)	5 (62.5%)	0
No anticoagulation	128 (32.2%)	123 (96.1%)	119 (93%)	19 (14.8%)
AHA 2014 recommendation
OAC indicated (CHA₂DS₂-VASC ≥2)	168 (42.2%)	152 (90.5%)	76 (45.2%)	25 (14.9%)
OAC should be considered (CHA₂DS₂-VASC 1)	122 (30.7%)	99 (81.1%)	115 (94.3%)	14 (11.5%)
No anticoagulation (CHA₂DS₂-VASC 0)	108 (27.1%)	101 (93.5%)	102 (94.4%)	16 (14.5%)
ESC 2016 recommendation
OAC indicated (CHA₂DS₂-VASC ≥2 for male ≥3 for female patients)	139 (34.9%)	124 (89.2%)	50 (36%)	23 (16.5%)
OAC should be considered (CHA₂DS₂-VASC 1 for male and 2 for female patients)	125 (31.4%)	117 (93.6%)	101 (80.8%)	12 (9.6%)
No anticoagulation (CHA₂DS₂-VASC 0 or only female)	134 (33.7%)	128 (95.5%)	125 (93.3%)	20 (14.9%)

ASA = acetylsalicylic acid; OAC = oral anticoagulation.

Table 5. Characteristics of Patients That Suffered from Stroke/TIA
A. General Characteristics of Patients Suffering from Stroke or TIA
#	Age/Sex	CHADS₂-Score	CHA₂DS₂-VASc-Score	Months to Stroke/TIA	OAC at Time of Stroke/TIA		Recurrence of AF/AT Prior to Stroke
1	58/M	0	0	8	Coumadin		No
2	71/M	0	1	44	Warfarin		No
3	71/F	1	3	51	Discontinued		Yes
4	58/F	2	3	1	Dabigatran		No
B. Detailed Distribution of the CHADS₂- and CHA₂DS₂-VASc-Score Components for Patients Suffering from Stroke or TIA
#	Female Gender	Age >65	Age >75	Hypertension	Diabetes	Hx of prior Stroke or TIA	Heart Failure	Vasc. Disease
1	No	No	No	No	No	No	No	No
2	No	Yes	No	No	No	No	No	No
3	Yes	Yes	No	Yes	No	No	No	No
4	Yes	No	No	Yes	Yes	No	No	No