Arrhythmias and Conduction Disturbances
Meta-Analysis of Efficacy and Safety of New Oral Anticoagulants Compared With Uninterrupted Vitamin K Antagonists in Patients Undergoing Catheter Ablation for Atrial Fibrillation

https://doi.org/10.1016/j.amjcard.2015.12.027Get rights and content

Anticoagulation in catheter ablation (CA) of atrial fibrillation (AF) is of paramount importance for prevention of thromboembolic events, and recent studies favor uninterrupted vitamin K antagonists (VKAs). We aimed to compare the efficacy and safety of new oral anticoagulants (NOACs) to uninterrupted VKAs for anticoagulation in CA by performing a meta-analysis. PubMed, EMBASE, the Cochrane Library, and Clinicaltrials.gov databases were searched for studies comparing NOACs with uninterrupted VKAs in patients who underwent CA for AF from January 1, 2000, to August 31, 2015. Odds ratio (OR) and Peto's OR (POR) were used to report for event rates >1% and <1%, respectively. A total of 11,686 patients with AF who underwent CA in 25 studies were included in this analysis. There was no significant difference between NOACs and uninterrupted VKAs in occurrence of stroke or transient ischemic attacks (POR 1.35, 95% CI 0.62 to 2.94) and major bleeding (POR 0.87, 95% CI 0.58 to 1.31), which were consistent in subgroup analysis of interrupted and uninterrupted NOACs. A lower risk of minor bleeding was observed with NOACs (OR 0.80, 95% CI 0.65 to 1.00), and no major differences were observed for the risk of thromboembolic events, cardiac tamponade or pericardial effusion requiring drainage, and groin hematoma. NOACs, whether interrupted preprocedure or not, were associated with equal rates of stroke or TIA and major bleeding complications and less risk of minor bleeding compared with uninterrupted VKAs in CA for AF.

Section snippets

Methods

PubMed, EMBASE, the Cochrane Library, and Clinicaltrials.gov databases were searched to identify published reports comparing NOACs to uninterrupted VKAs in patients who underwent CA for AF from January 1, 2000, to August 31, 2015. The main key words we used were “atrial fibrillation,” “catheter ablation,” “anticoagulants,” “warfarin,” “dabigatran,” “rivaroxaban,” “apixaban,” “factor Xa inhibitor,” and “factor IIa inhibitor” (refer to Supplementary File 1 for details of search strategy). The

Results

The flowchart of detailed search process was illustrated in Figure 1. From a total of 2,692 potentially relevant reports, 25 citations, involving 11,686 patients, fulfilled selection criteria and were finally included in this meta-analysis.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 Of the identified studies, only one was RCT,20 and the remaining were observational studies. Eighteen studies were published as full-text studies,3, 4, 5, 6, 7, 8, 9,

Discussion

The present study was the first and most comprehensive meta-analysis so far comparing the efficacy and safety of NOACs to uninterrupted VKAs in patients undergoing rhythm control management of AF by CA, with 25 selected studies that included 11,686 participants. This meta-analysis incorporating all these studies showed that NOACs, whether discontinued preprocedure or not, had comparable efficacy in terms of ischemic stroke or TIA prevention and similar safety with respect to the occurrence of

Disclosures

The authors have no conflicts of interest to disclose.

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      In patients using VKA, quality of anticoagulation control is important, and a TTR > 70% should be maintained to improve outcomes [5]. The introduction of the non-vitamin K antagonist anticoagulants (NOACs), including factor II inhibitor, dabigatran, factor X inhibitors, rivaroxaban, apixaban and edoxaban, has changed the landscape of stroke prevention in AF patients worldwide, offering relatively improved efficacy, safety and convenience compared with the traditional VKAs [6–12]. Indeed, all NOACs are associated with a reduced risk for intracranial hemorrhage (ICH), even compared with well-controlled VKAs [13,14].

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      Currently, uninterrupted vitamin K antagonism during the ablation procedure has been widely accepted to reduce stroke events without increasing bleeding compared with interrupted warfarin treatment (4). Recent studies have also reported that perioperative uninterrupted DOAC use was similarly feasible and safe compared with uninterrupted warfarin treatment (5–15). It is unclear whether these results can be applied to elderly patients who undergo catheter ablation for AF.

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