Anticoagulation After Catheter Ablation of Atrial Fibrillation: An Unnecessary Evil?

A Systematic Review and Meta-analysis

Riccardo Proietti MD, PhD; Ahmed AlTurki MD; Luigi Di Biase MD, PhD; Paolo China MD; Giovanni Forleo MD; Andrea Corrado MD; Elena Marras MD; Andrea Natale MD; Sakis Themistoclakis MD

Disclosures

J Cardiovasc Electrophysiol. 2019;30(4):468-478. 

In This Article

Abstract and Introduction

Abstract

Background: Anticoagulation in patients with atrial fibrillation (AF) is currently based on clinical parameters (CHA2DS 2-VASc score) that have been shown to predict cerebrovascular events (CVE). Controversy exists as to whether CVE risk persists unmodified after successful catheter ablation, as observational studies suggest a lower risk of CVE. Current guidelines recommend continued oral anticoagulation (OAC) based on the CHA 2DS 2-VASc score risk profile.

Methods: We conducted a systematic literature review of all studies published up to July 31, 2018, that reported CVE after catheter ablation of AF and compared patients on or off OAC. Random-effects models were used to demonstrate the risk of CVE and major bleeding in on-OAC vs off-OAC patients. This analysis was further stratified by CHADS2 and CHA 2DS2-VASc score.

Results: We retained 16 studies, 10 prospective cohort and 6 retrospective cohort, that met inclusion criteria, and which enrolled 25 177 patients: 13 166 off-OAC and 12 011 on-OAC. No significant difference in the incidence of CVE emerged between on-OAC and off-OAC patients after AF ablation (risk ratio, 0.66; confidence interval [CI], 0.38, 1.15). Similar results were found after stratification by CHADS2 and CHA 2DS 2-VASc score. Off-OAC patients suffered significantly less bleeding than those on OAC (RR, 0.17; CI, 0.09, 0.34). Of note, the percentage of patients with AF recurrence impacts the treatment effect in the two groups ( P = 0.001).

Conclusions: In this metanalysis, the risk-benefit ratio favored the suspension of OAT after successful AF ablation even in patients at moderate-high risk. Whether the reported results can be extended also to non-vitamin K antagonist oral anticoagulants warrants further investigations.

Introduction

Atrial fibrillation (AF) is the most frequent arrhythmia worldwide and is associated with a fivefold increased risk of cerebrovascular events (CVE).[1,2] Oral anticoagulation (OAC) markedly reduces the risk of CVE; however, this treatment is associated with an increased risk of major bleeding.[1,2] Decision-making regarding OAC, therefore, needs to balance the risk of CVE against the risk of bleeding.

The risk of CVE is assessed by means of CHADS2 [Congestive heart failure, Hypertension, Age ≥75, Diabetes, Stroke (doubled)] score and, more recently, the CHA2DS2-VASc (Congestive heart failure/left ventricular dysfunction, Hypertension, Age ≥75 [doubled], Diabetes, Stroke [doubled]—Vascular disease, age 65-74, and Sex category [female]) score. OAC therapy is currently recommended for patients with a CHA2DS2-VASc score of two or more and should be considered for those with a CHA2DS2-VASc score of one.[3,4]

Several trials of antiarrhythmic drugs have recorded similar rates of CVE in patients on a rhythm-control strategy and in those on rate control.[5] Consequently, although the introduction of AF catheter ablation has radically changed the management of AF worldwide, and has yielded better outcomes than medical therapy,[6–11] it has not modified the indication for OAC in patients successfully treated with AF ablation.[1,2] In the last few years, several studies have reported a low incidence of CVE in patients successfully treated with AF ablation in which OAC was discontinued after ablation[12–15] indicating that the risk-benefit ratio of OAC needs to be evaluated in these patients.

In this systematic review, all the available data on the incidence of CVE and bleeding in patients on and off OAC after catheter ablation were pooled together to assess the risks and benefits of OAC after AF ablation.

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