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Gjermeni D, Saglam NP, Olivier CB, Kühlkamp V. Comparison of phenprocoumon with direct oral anticoagulants in catheter ablation of atrial fibrillation. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead065. [PMID: 37427356 PMCID: PMC10329261 DOI: 10.1093/ehjopen/oead065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/18/2023] [Accepted: 06/15/2023] [Indexed: 07/11/2023]
Abstract
Aims In patients undergoing catheter ablation for atrial fibrillation (AF), direct oral anticoagulants (DOACs) are as effective and safe as the vitamin K antagonist (VKA) warfarin. Phenprocoumon has a different pharmacokinetic profile compared with warfarin and is the most used VKA in Germany. The aim of the study was to compare DOAC with phenprocoumon. Methods and results In this retrospective single-centre cohort study, 1735 patients who underwent 2219 consecutive catheter ablations for AF between January 2011 and May 2017 were included. All patients were in-hospital for at least 48 h after catheter ablation. The primary outcome was defined as peri-procedural thrombo-embolic events. The secondary outcome was any bleeding according to the International Society on Thrombosis and Haemostasis (ISTH). The mean age of the patients was 63.3 years. Phenprocoumon was prescribed in 929 (42%) of the cases, and in 697 (31%) dabigatran, 399 (18%) rivaroxaban, and 194 (9%) apixaban. During hospitalization, 37 (1.6%) thrombo-embolic events occurred, including 23 transient ischaemic attacks (TIAs). Compared with the use of phenoprocoumon, the use of DOAC was significantly associated with a lower thrombo-embolic risk [16 (1.2%) vs. 21 (2.2%), odds ratio (OR)], 0.5 [95% confidence interval (CI) 0.2-0.9], P = 0.04. No statistically significant association with bleeding risk was observed [phenprocomoun: 122 (13%); DOAC: 163 (12.6%); OR 0.9 (95% CI 0.7-1.2); P = 0.70]. Interruption of oral anticoagulation (OAC) was associated with an increased risk for thrombo-embolic complications [OR 2.2 (1.1-4.3); P = 0.031], and bleeding [OR 2.5 (95% CI 1.8-3.2), P = 0.001]. Conclusion In patients undergoing catheter ablation for AF, the use of DOAC was associated with a reduced risk of thrombo-embolic events compared with phenprocoumon. Non-interrupted oral anticoagulation (OAC) therapy was associated with a reduced risk of peri-procedural thrombo-embolic and any bleeding complications.
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Affiliation(s)
| | | | - Christoph B Olivier
- Department of Cardiology and Angiology, Heart Center Freiburg-Bad Krozingen Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
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2
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The non-vitamin K antagonist oral anticoagulants and heparin-induced prolongation of the activated coagulation time. Vascul Pharmacol 2022; 144:106994. [DOI: 10.1016/j.vph.2022.106994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/18/2022] [Accepted: 04/04/2022] [Indexed: 11/20/2022]
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3
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 468] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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Yagishita A, Goya M, Iesaka Y, Nitta J, Takahashi A, Nagata Y, Hachiya H, Inaba O, Inamura Y, Tanaka Y, Watanabe K, Tao S, Shirai Y, Yamamoto T, Shiohira S, Akiyoshi K, Sekigawa M, Maeda S, Sasaki T, Takahashi Y, Kawabata M, Hirao K. A prospective multicenter study of direct comparison of feasibility and safety of pulmonary vein isolation using the minimally interrupted apixaban between second-generation cryoballoon and radiofrequency ablation of paroxysmal atrial fibrillation: J-HIT apixaban. J Arrhythm 2020; 36:617-623. [PMID: 32782630 PMCID: PMC7411193 DOI: 10.1002/joa3.12392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The feasibility and safety of pulmonary vein isolation (PVI) using cryoballoon (CB) for paroxysmal atrial fibrillation (PAF) with minimally interrupted apixaban has not fully explored. METHODS In this multicenter, randomized prospective study, we enrolled patients with PAF undergoing CB or radiofrequency (RF) ablation with interrupted (holding 1 dose) apixaban. The primary composite end point consisted of bleeding events, including pericardial effusion and major bleeding requiring blood transfusion, or thromboembolic events at 4 weeks after ablation; secondary end points included early recurrence of AF and procedural duration. RESULTS A total of 250 patients underwent PVI (125 assigned to the RF ablation and 125 assigned to the CB ablation). The primary end point occurred in 1 patient in the CB ablation group (0.8%; 90% confidence interval [CI], 0.04 to 3.70) and 3 patients in the RF group (2.4%, P = .622; risk ratio, 0333; 90% CI, 0.05 to 2.20). All events were pericardial effusion, all of whom recovered after pericardiocentesis. Early recurrence of AF occurred in 4 patients (3.2%) in the RF group and in 6 patients (4.8%) in the CB group (P = .749). The procedural duration was shorter in the CB group than that in the RF group (136.5 ± 39.9 vs 179.5 ± 44.8 min, P < .001). CONCLUSION CB ablation with minimally interrupted apixaban was feasible and safe in patients with PAF undergoing PVI, which was equivalent to RF ablation.
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Affiliation(s)
- Atsuhiko Yagishita
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
| | - Masahiko Goya
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
| | - Yoshito Iesaka
- Cardiovascular CenterTsuchiura Kyodo HospitalTsuchiuraJapan
| | - Junichi Nitta
- Department of CardiologySaitama Red Cross HospitalSaitamaJapan
| | | | | | | | - Osamu Inaba
- Department of CardiologySaitama Red Cross HospitalSaitamaJapan
| | | | - Yasuaki Tanaka
- Cardiovascular CenterYokosuka Kyosai HospitalYokosukaJapan
| | - Keita Watanabe
- Division of CardiologyMusashino Red Cross HospitalTokyoJapan
| | - Susumu Tao
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
| | - Yasuhiro Shirai
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
| | - Tasuku Yamamoto
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
| | - Shinya Shiohira
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
| | - Kikou Akiyoshi
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
| | - Masahiro Sekigawa
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
| | - Shingo Maeda
- Department of Advanced Arrhythmia ResearchTokyo Medical and Dental UniversityTokyoJapan
| | - Takeshi Sasaki
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
| | - Yoshihide Takahashi
- Department of Advanced Arrhythmia ResearchTokyo Medical and Dental UniversityTokyoJapan
| | - Mihoko Kawabata
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
| | - Kenzo Hirao
- Department of Cardiovascular Medicine/Heart Rhythm CenterTokyo Medical and Dental UniversityTokyoJapan
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5
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Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbüchel H. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2019; 39:1330-1393. [PMID: 29562325 DOI: 10.1093/eurheartj/ehy136] [Citation(s) in RCA: 1286] [Impact Index Per Article: 257.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | | | | | - Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin and Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Ronan Collins
- Age-Related Health Care & Stroke-Service, Tallaght Hospital, Dublin Ireland
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK, and Imperial College
| | - Hein Heidbüchel
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Antwerp University and University Hospital, Antwerp, Belgium
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6
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Thromboembolism and bleeding risk in atrial fibrillation ablation with uninterrupted anticoagulation between new oral anticoagulants and vitamin K antagonists: insights from an updated meta-analysis. J Thromb Thrombolysis 2019; 50:201-210. [DOI: 10.1007/s11239-019-01989-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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7
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Perioperative Safety and Efficacy of Different Anticoagulation Strategies With Direct Oral Anticoagulants in Pulmonary Vein Isolation: A Meta-Analysis. JACC Clin Electrophysiol 2019; 4:794-806. [PMID: 29929673 DOI: 10.1016/j.jacep.2018.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/11/2018] [Accepted: 04/19/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the safety and efficacy of uninterrupted and interrupted direct oral anticoagulant (DOAC) administration in patients undergoing pulmonary vein isolation (PVI). BACKGROUND The optimal periprocedural management of DOACs in patients undergoing PVI is not well defined, and different strategies are used. METHODS A systematic search of PubMed/MEDLINE, Ovid/MEDLINE, and EMBASE was performed. Three strategies for periprocedural DOAC administration were considered: uninterrupted, mildly interrupted (<12 h), and interrupted (≥12 h). Primary endpoints were major bleeding (MB) and thromboembolic (TE) complications; pooled weighted mean incidence (WMI) was calculated using a random-effects model. A secondary endpoint was the WMI of overall bleeding (OB). RESULTS The analysis included 43 studies for a total of 8,362 patients. DOACs showed similar safety and efficacy in the 3 subgroups. The WMI of MB was 1.02%, 1.49%, and 1.17% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively; the WMI of TE complications was 0.16%, 0.46%, and 0.49% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively, with no heterogeneity. OB appeared to be higher in uninterrupted (6.33%) and mildly interrupted (8.62%) groups compared with the interrupted (3.53%), with substantial heterogeneity among studies. No interaction was found between the incidence of MB and TE complications and different DOACs. CONCLUSIONS In patients undergoing PVI, these 3 anticoagulation strategies may have similar safety and efficacy in terms of MB and TE complications. OB appears to be higher in uninterrupted and mildly interrupted strategies compared with the interrupted strategy. No substantial differences were observed among DOACs regarding the incidence of MB and TE complications.
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8
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Osaka Y, Ono Y, Tao S, Goto K, Miyazaki T, Suzuki A, Kurihara K, Otomo K, Hirao K. Feasibility and safety of uninterrupted apixaban in patients undergoing radiofrequency ablation for atrial fibrillation. J Interv Card Electrophysiol 2019; 58:35-41. [DOI: 10.1007/s10840-019-00563-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
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Trujillo TC, Dobesh PP, Crossley GH, Finks SW. Contemporary Management of Direct Oral Anticoagulants During Cardioversion and Ablation for Nonvalvular Atrial Fibrillation. Pharmacotherapy 2018; 39:94-108. [PMID: 30548542 DOI: 10.1002/phar.2205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
As overall prevalence of atrial fibrillation (AF) continues to rise, the number of patients who undergo ablation, or electrical/chemical cardioversion, to restore normal sinus rhythm continues to increase as well. As direct oral anticoagulants (DOACs) have continued to be incorporated into clinical practice for long-term anticoagulation for AF, experience with how best to manage use of DOACs during electrophysiologic procedures is evolving. This review is intended to provide health care providers with a summary of current evidence regarding the use of DOACs during cardioversion and catheter ablation and provide key considerations for their use during such electrophysiologic procedures. PubMed and MEDLINE were searched from inception through June 2018 for studies in humans comparing DOACs alone or against vitamin K antagonists (VKAs) in adult patients (> 18 yrs) who underwent cardioversion or AF catheter ablation using the following key words: "rivaroxaban," "dabigatran," "apixaban," "edoxaban," "non-vitamin K antagonists," "direct or new oral anticoagulants," "warfarin," "vitamin K antagonists," "cardioversion," "ablation of atrial fibrillation," "uninterrupted," and "catheter ablation." Four retrospective studies and three prospective trials comparing DOACs with VKA in patients undergoing cardioversion and three prospective studies in patients undergoing catheter ablation for AF were identified. Observational data and meta-analyses were also critically reviewed. Prospective trials to date suggest similar efficacy and safety with using DOACs in the setting of cardioversion and AF ablation compared to traditional therapy with VKA, with or without bridging. Injectable anticoagulant overlap can be avoided in patients receiving DOACs in the setting of cardioversion for AF. Minimal interruption in anticoagulation may be only necessary for AF ablation in those with highest bleeding risk, such as in renal dysfunction and where drug-drug interactions may increase risk for anticoagulant accumulation. Periprocedural advantages of DOACs include convenience, rapid and predictable onset of effect, improved patient satisfaction, and potential for reduced costs.
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Affiliation(s)
- Toby C Trujillo
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Paul P Dobesh
- Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
| | - George H Crossley
- Department of Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shannon W Finks
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee, Memphis, Tennessee
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10
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De Heide J, Vroegh CJ, Bhagwandien RE, Wijchers SA, Szili-Torok T, Zijlstra F, Lenzen MJ, Yap SC. Minimally interrupted novel oral anticoagulant versus uninterrupted vitamin K antagonist during atrial fibrillation ablation. J Interv Card Electrophysiol 2018; 53:341-346. [PMID: 30074120 PMCID: PMC6292967 DOI: 10.1007/s10840-018-0417-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/18/2018] [Indexed: 12/28/2022]
Abstract
PURPOSE The safety and efficacy of a minimally interrupted novel oral anticoagulant (NOAC) strategy at the time of atrial fibrillation (AF) ablation is uncertain. The purpose of this study was to compare rates of bleeding and thromboembolic events between minimally interrupted NOAC and uninterrupted vitamin K antagonist (VKA) in patients undergoing AF ablation. METHODS This was a retrospective single-center cohort study of consecutive patients who underwent AF catheter ablation between January 2013 and April 2017. Endpoints included major bleeding, clinically relevant non-major bleeding and systemic thromboembolic event from the time of ablation through 30 days. Bleeding events were defined by the Bleeding Academic Research Consortium (BARC) and International Society on Thrombosis and Haemostasis (ISTH). RESULTS A total of 637 patients were included in the analysis, 520 patients used uninterrupted VKA and 117 patients minimally interrupted NOAC (dabigatran: n = 68; apixaban: n = 30; rivaroxaban, n = 14; edoxaban, n = 5). The rate of clinically relevant non-major bleeding was lower in the NOAC group in comparison to the VKA group (BARC type 2: 2.6% versus 8.3%, P = 0.03; ISTH: 0% versus 3.8%, P = 0.03). Rates of major bleeding were similar between groups (BARC type 3 to 5: 3.4% versus 4.2%, P = NS; ISTH: 6.0% versus 8.7%, P = NS; for NOAC and VKA groups, respectively). Rates of systemic embolism were 0% with minimally interrupted NOAC, and 0.6% with uninterrupted VKA (P = NS). CONCLUSIONS In patients undergoing AF ablation, anticoagulation with minimally interrupted NOAC was associated with fewer clinically relevant non-major bleeding events in comparison with uninterrupted VKA without compromising thromboembolic safety.
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Affiliation(s)
- John De Heide
- Department of Cardiology, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Christiaan J Vroegh
- Department of Cardiology, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Rohit E Bhagwandien
- Department of Cardiology, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Sip A Wijchers
- Department of Cardiology, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Mattie J Lenzen
- Department of Cardiology, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - S C Yap
- Department of Cardiology, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.
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11
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Ge Z, Faggioni M, Baber U, Sartori S, Sorrentino S, Farhan S, Chandrasekhar J, Vogel B, Qadeer A, Halperin J, Reddy V, Dukkipati S, Dangas G, Mehran R. Safety and efficacy of nonvitamin K antagonist oral anticoagulants during catheter ablation of atrial fibrillation: A systematic review and meta-analysis. Cardiovasc Ther 2018; 36:e12457. [PMID: 29971964 DOI: 10.1111/1755-5922.12457] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 12/13/2022] Open
Abstract
AIMS Catheter ablation for atrial fibrillation (AF) is associated with a transitory increase in the risk of both thromboembolic and bleeding events. Evidence on the use of nonvitamin K antagonist oral anticoagulants (NOACs) in patients undergoing AF ablation mostly comes from small observational studies, underpowered to detect differences in clinical outcomes between NOACs and vitamin K antagonists (VKAs) treated patients. This updated meta-analysis aimed to determine the safety and efficacy of periprocedural anticoagulation with NOACs compared with VKAs in AF patients undergoing catheter ablation. METHODS We searched MEDLINE, Cochrane library, and web sources for randomized and observational studies comparing periprocedural treatment with NOACs and VKAs in patients undergoing AF ablation. The primary safety endpoint was major bleeding events, and the primary efficacy endpoint was thromboembolic events (a composite of systemic thromboembolism, transient ischemic attack, and stroke). RESULTS A total of 29 studies with 12 644 patients were included in the meta-analysis. Overall, patients on NOACs had a significantly lower risk of major bleeding compared to VKAs either in observational studies (Peto OR 0.68; 95% CI: 0.48-0.95; P = 0.022; I2 = 20%) or in RCTs (Peto OR 0.30; 95% CI: 0.14-0.62; P = 0.001; I2 = 28%). Uninterrupted NOACs reduced the risk of major bleeding when compared to uninterrupted VKAs (Peto OR 0.66; 95% CI: 0.45-0.96; P = 0.028; I2 = 1%), similarly, interrupted NOACs lowered the risk of major bleeding compared to interrupted VKAs (Peto OR 0.29; 95% CI: 0.13-0.66; P = 0.003; I2 = 0%; Pinteraction = 0.076). The rate of thromboembolic complications was very low and did not significantly differ between the study groups either in observational studies (Peto OR 0.91; 95% CI: 0.49-1.67; P = 0.755; I2 = 0%) or in RCTs (Peto OR 0.14; 95% CI: 0.01-1.30; P = 0.083; I2 = 0%). CONCLUSIONS Use of NOACs compared to VKAs significantly reduced the risk of bleeding in patients with AF ablation. Similarly, the risk of bleeding was lower with uninterrupted NOACs than with uninterrupted VKAs, and with interrupted NOACs than with interrupted VKAs. The rate of thromboembolic complications was extremely low in both study groups without any differences.
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Affiliation(s)
- Zhen Ge
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York.,Division of cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Michela Faggioni
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Samantha Sartori
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Sabato Sorrentino
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Serdar Farhan
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Jaya Chandrasekhar
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Birgit Vogel
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Abdul Qadeer
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Jonathan Halperin
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Vivek Reddy
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Srinivas Dukkipati
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - George Dangas
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
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Continuous and minimally-interrupted direct oral anticoagulant are both safe compared with vitamin K antagonist for atrial fibrillation ablation: An updated meta-analysis. Int J Cardiol 2018; 262:51-56. [DOI: 10.1016/j.ijcard.2018.03.095] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/07/2018] [Accepted: 03/19/2018] [Indexed: 11/21/2022]
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13
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Nakamura K, Naito S, Sasaki T, Take Y, Minami K, Kitagawa Y, Motoda H, Inoue M, Otsuka Y, Niijima K, Yamashita E, Sugai Y, Kumagai K, Koyama K, Funabashi N, Oshima S. Uninterrupted vs. interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: a prospective randomized single-centre study on post-ablation thrombo-embolic and haemorrhagic events. Europace 2018; 21:259-267. [DOI: 10.1093/europace/euy148] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/31/2018] [Indexed: 02/01/2023] Open
Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Yoshiyuki Kitagawa
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Hiroyuki Motoda
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Yoshimitsu Otsuka
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Katsura Niijima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Yoshinao Sugai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Koji Kumagai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Shigeru Oshima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
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Diener HC, Aisenberg J, Ansell J, Atar D, Breithardt G, Eikelboom J, Ezekowitz MD, Granger CB, Halperin JL, Hohnloser SH, Hylek EM, Kirchhof P, Lane DA, Verheugt FWA, Veltkamp R, Lip GYH. Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 1. Eur Heart J 2018; 38:852-859. [PMID: 26848149 DOI: 10.1093/eurheartj/ehv643] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/09/2015] [Indexed: 01/05/2023] Open
Abstract
Patients with atrial fibrillation (AF) have a high risk of stroke and mortality, which can be considerably reduced by oral anticoagulants (OAC). Recently, four non-vitamin-K oral anticoagulants (NOACs) were compared with warfarin in large randomized trials for the prevention of stroke and systemic embolism. Today's clinician is faced with the difficult task of selecting a suitable OAC for a patient with a particular clinical profile or a particular pattern of risk factors and concomitant diseases. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. NOACs for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In the first of a two-part review, we discuss the choice of NOAC for stroke prevention in the following subgroups of patients with AF: (i) stable coronary artery disease or peripheral artery disease, including percutaneous coronary intervention with stenting and triple therapy; (ii) cardioversion, ablation and anti-arrhythmic drug therapy; (iii) mechanical valves and rheumatic valve disease, (iv) patients with time in therapeutic range of >70% on warfarin; (v) patients with a single stroke risk factor (CHA2DS2VASc score of 1 in males, 2 in females); and (vi) patients with a single first episode of paroxysmal AF. Although there are no major differences in terms of efficacy and safety between the NOACs for some clinical scenarios, in others we are able to suggest that particular drugs and/or doses be prioritized for anticoagulation.
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Affiliation(s)
| | | | - Jack Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, USA
| | - Dan Atar
- Division of Medicine, Oslo University Hospital, Ullevål and University of Oslo, Oslo, Norway
| | - Günter Breithardt
- Division of Rhythmology, Department of Cardiovascular Medicine, Hospital of the University Münster, Münster, Germany
| | - John Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Michael D Ezekowitz
- Cardiovascular Research Foundation, New York, NY, USA.,Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA.,Lankenau Medical Center, Wynnewood, PA, USA
| | | | - Jonathan L Halperin
- Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J. W. Goethe University, Frankfurt, Germany
| | - Elaine M Hylek
- Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham, UK.,Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
| | - Deirdre A Lane
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | | | | | - Gregory Y H Lip
- University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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15
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Periablation Anticoagulation: Translating Research Into Clinical Practice. JACC Clin Electrophysiol 2018; 4:589-591. [PMID: 29798784 DOI: 10.1016/j.jacep.2018.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/25/2018] [Indexed: 11/23/2022]
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16
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Yanagisawa S, Inden Y, Fujii A, Ando M, Funabiki J, Murase Y, Takenaka M, Otake N, Ikai Y, Sakamoto Y, Shibata R, Murohara T. Uninterrupted Direct Oral Anticoagulant and Warfarin Administration in Elderly Patients Undergoing Catheter Ablation for Atrial Fibrillation: A Comparison With Younger Patients. JACC Clin Electrophysiol 2018; 4:592-600. [PMID: 29798785 DOI: 10.1016/j.jacep.2018.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/15/2018] [Accepted: 02/16/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The goal of this study was to evaluate the efficacy and safety of uninterrupted direct oral anticoagulant (DOAC) use and uninterrupted warfarin administration in elderly patients undergoing catheter ablation for atrial fibrillation (AF). BACKGROUND There is limited knowledge regarding the uninterrupted use of oral anticoagulant agents in elderly patients undergoing catheter ablation for AF. METHODS This retrospective study included 2,164 patients (n = 325 ≥75 years of age and n = 1,839 <75 years of age) who underwent catheter ablation for AF. All the patients received uninterrupted oral anticoagulant agents during the procedure. We investigated the occurrences of periprocedural events and compared these between the DOAC and warfarin groups of the elderly and younger groups. RESULTS Major bleeding events (3.1% vs. 1.3%; p = 0.023) and minor bleeding events (9.2% vs. 5.0%; p = 0.002), except for thromboembolic events (0% vs. 0.8%; p = 0.248), were significantly higher in the elderly group than in the younger group. No significant differences in thromboembolic and bleeding events were found between the DOAC and warfarin groups of both the elderly and younger groups. Adverse complications did not differ between the groups after adjustment using propensity score matching analysis. Multivariate analysis revealed that lower body weight (odds ratio: 0.96; p = 0.010) and antiplatelet drug use (odds ratio: 2.21; p = 0.039) were independent predictors of adverse events in the elderly group. CONCLUSIONS The periprocedural bleeding risk during the use of uninterrupted oral anticoagulants was higher in the elderly group than in the younger group. This area needs more attention for these patients in whom caution is required.
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Affiliation(s)
- Satoshi Yanagisawa
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Aya Fujii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Monami Ando
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junya Funabiki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yosuke Murase
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaki Takenaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Noriaki Otake
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiro Ikai
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Sakamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Rei Shibata
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Brinkmeier-Theofanopoulou M, Tzamalis P, Wehrkamp-Richter S, Radzewitz A, Merkel M, Schymik G, van Mark G, Bramlage P, Schmitt C, Luik A. Periprocedural anticoagulation during left atrial ablation: interrupted and uninterrupted vitamin K-antagonists or uninterrupted novel anticoagulants. BMC Cardiovasc Disord 2018; 18:71. [PMID: 29703158 PMCID: PMC5924498 DOI: 10.1186/s12872-018-0804-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 04/04/2018] [Indexed: 12/21/2022] Open
Abstract
Background There is a lack of data on anticoagulation requirements during ablation of atrial fibrillation (AF). This study compares different oral anticoagulation (OAC) strategies to evaluate risk of bleeding and thromboembolic complications. Methods We conducted a single-centre study in patients undergoing left atrial ablation of AF. Three groups were defined: 1) bridging: interrupted vitamin-K-antagonists (VKA), INR ≤2, and bridging with heparin; 2) VKA: uninterrupted VKA and INR of > 2; 3) DOAC: uninterrupted direct oral anticoagulants. Bleeding complications, thromboembolic events and peri-procedural heparin doses were assessed. Results In total, 780 patients were documented. At 48 h, major complications were more common in the bridging group compared to uninterrupted VKA and DOAC groups (OR: 3.42, 95% CI: 1.29–9.10 and OR: 3.01, 95% CI: 1.19–7.61), largely driven by differences in major pericardial effusion (OR: 4.86, 95% CI: 1.56–15.99 and OR: 4.466, 95% CI, 1.52–13.67) and major vascular events (OR: 2.92, 95% CI: 0.58–14.67 and OR: 9.72, 95% CI: 1.00–94.43). Uninterrupted VKAs and DOACs resulted in similar odds of major complications (overall OR: 1.14, 95% CI: 0.44–2.92), including cerebrovascular events (OR: 1.21, 95% CI: 0.27–5.45). However, whereas only TIAs were observed in DOAC and bridging groups, strokes also occurred in the VKA group. Rates of minor complications (pericardial effusion, vascular complications, gastrointestinal hemorrhage) and major/minor groin hemorrhage were similar across groups. Conclusion Our dataset illustrates that uninterrupted VKA and DOAC have a better risk-benefit profile than VKA bridging. Bridging was associated with a 4.5× increased risk of complications and should be avoided, if possible.
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Affiliation(s)
- Maria Brinkmeier-Theofanopoulou
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133, Karlsruhe, Germany
| | - Panagiotis Tzamalis
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133, Karlsruhe, Germany
| | - Susan Wehrkamp-Richter
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133, Karlsruhe, Germany
| | - Andrea Radzewitz
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133, Karlsruhe, Germany
| | - Matthias Merkel
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133, Karlsruhe, Germany
| | - Gerhard Schymik
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133, Karlsruhe, Germany
| | - Gesine van Mark
- Institute for Pharmacology and Preventive Medicine, Mahlow, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Mahlow, Germany
| | - Claus Schmitt
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133, Karlsruhe, Germany
| | - Armin Luik
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133, Karlsruhe, Germany.
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18
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Periprocedural Management of Direct Oral Anticoagulants Surrounding Cardioversion and Invasive Electrophysiological Procedures. Cardiol Rev 2018; 26:245-254. [PMID: 29621010 PMCID: PMC6082596 DOI: 10.1097/crd.0000000000000188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Supplemental Digital Content is available in the text. As direct oral anticoagulants (DOACs) have demonstrated favorable efficacy and safety outcomes compared with vitamin K antagonists for the treatment and prevention of venous thromboembolism and the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, their role in the management of anticoagulation during electrophysiological procedures continues to evolve. At present, guidelines are limited regarding specific recommendations for the use of DOACs in these clinical settings. Here, we review available data regarding the risks and benefits associated with various periprocedural anticoagulation management approaches when patients receiving DOACs undergo electrophysiologic procedures including cardioversion, ablation, and device implantation. This discussion is intended to provide clinicians with an overview of available evidence and best practices to minimize the risk of both thromboembolic and bleeding events in the periprocedural setting.
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19
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Lee KH, Joung B, Lee SR, Hwang YM, Park J, Baek YS, Park YM, Park JK, Park HC, Park HW, Lee YS, Choi KJ. 2018 KHRS Expert Consensus Recommendation for Oral Anticoagulants Choice and Appropriate Doses: Specific Situation and High Risk Patients. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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20
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Leiria TLL, Medeiros AK, Almeida ED, Ley ALG, Santos CBLD, Sant'Anna RT, Kruse ML, Pires LM, Lima GGD. Uninterrupted Use of Oral Anticoagulants for the Ablation of Atrial Flutter: A Single Center Cohort of 154 Patients. Arq Bras Cardiol 2018; 110:151-156. [PMID: 29466488 PMCID: PMC5855908 DOI: 10.5935/abc.20180001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 08/09/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The uninterrupted use of oral anticoagulation (OAC) with vitamin K antagonists (VKAs) for electrophysiology procedures has been more and more recommended. The clinical practice in our service recommends the continuous use of these drugs for atrial flutter ablation. There is little evidence as to the uninterrupted use of non-vitamin K antagonist oral anticoagulants (NOACs) in this scenario. OBJECTIVE To compare the rates of complications related with the uninterrupted use of different types of oral anticoagulants in patients referred to atrial flutter (AFL) ablation. METHODS Historical, single-center cohort of ablation procedures by AFL conducted from November 2012 to April 2016. The primary outcome was the occurrence of hemorrhagic or embolic complication during the procedure. The secondary outcome was the occurrence of stroke or transient ischemic attack (TIA) in follow-up. The statistical significance level was 5%. RESULTS There were 288 ablations per AFL; 154 were carried out with the uninterrupted use of OAC (57.8% with VKA and 42.2% with NOAC). Mean age was 57 ± 13 years. The rate of hemorrhagic complication during the procedure was 3% in each group (p = NS). The rate of stroke/TIA was, respectively, of 56/1,000 people-year in the VKA group against zero/1,000 people-year in the NOAC group (p = 0.02). CONCLUSION In our population there were no hemorrhagic complications regarding the procedure of OAC use uninterruptedly, including NOACs. There was higher occurrence of stroke/TIA in the follow-up of the group of patients undergoing VKAs; however, this difference may not only be a result of the type of OAC used.
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Affiliation(s)
- Tiago Luiz Luz Leiria
- Instituto de Cardiologia / Fundação Universitária de Cardiologia - IC/FUC, Porto Alegre, RS - Brazil
| | | | - Eduardo Dytz Almeida
- Instituto de Cardiologia / Fundação Universitária de Cardiologia - IC/FUC, Porto Alegre, RS - Brazil
| | - Antonio Lessa Gaudie Ley
- Instituto de Cardiologia / Fundação Universitária de Cardiologia - IC/FUC, Porto Alegre, RS - Brazil
| | | | - Roberto Toffani Sant'Anna
- Instituto de Cardiologia / Fundação Universitária de Cardiologia - IC/FUC, Porto Alegre, RS - Brazil
| | - Marcelo Lapa Kruse
- Instituto de Cardiologia / Fundação Universitária de Cardiologia - IC/FUC, Porto Alegre, RS - Brazil
| | - Leonardo Martins Pires
- Instituto de Cardiologia / Fundação Universitária de Cardiologia - IC/FUC, Porto Alegre, RS - Brazil
| | - Gustavo Glotz de Lima
- Instituto de Cardiologia / Fundação Universitária de Cardiologia - IC/FUC, Porto Alegre, RS - Brazil
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Kottmaier M, Bourier F, Pausch H, Reents T, Semmler V, Telishevska M, Koch-Büttner K, Lennerz C, Lengauer S, Kornmayer M, Rousseva E, Brooks S, Brkic A, Ammar-Busch S, Kaess B, Dillier R, Grebmer C, Kolb C, Hessling G, Deisenhofer I. Safety of Uninterrupted Periprocedural Edoxaban Versus Phenprocoumon for Patients Who Underwent Left Atrial Catheter Ablation Procedures. Am J Cardiol 2018; 121:445-449. [PMID: 29289359 DOI: 10.1016/j.amjcard.2017.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/30/2017] [Accepted: 11/07/2017] [Indexed: 01/24/2023]
Abstract
Data about the safety of edoxaban in patients who underwent left atrial (LA) radiofrequency (RF) ablation procedures are lacking. This study sought to compare the safety of uninterrupted edoxaban with uninterrupted phenprocoumon administration during LA RF ablation for atrial fibrillation and atrial tachycardia. In total, 231 patients (mean age 64 ± 11years, male 71%) who underwent LA RF ablation under continuous oral anticoagulation (OAC) with edoxaban or phenprocoumon were included in the study. Patients on uninterrupted edoxaban (60 mg or 30 mg/day for at least 4 weeks) were matched for gender, age and type of arrhythmia with 2 patients on uninterrupted phenprocoumon (international normalized ratio 2 to 3). We identified 77 consecutive patients on edoxaban and n = 154 patients on phenprocoumon. Heparin was administered periprocedurally to achieve an activated clotting time of 280 to 300 seconds. No protamine was administered periprocedurally. The primary end point was a composite of bleeding, thromboembolic events, and death. The primary end point was met in 9 patients in the edoxaban group and in 22 patients in the phenprocoumon group (p = 0.69). No patient in either group died or had a thromboembolic complication. No major bleeding complication was observed in the edoxaban group, whereas one was found in 1 patient in the phenprocoumon group (p ≥0.99). Minor bleeding complications occurred in 9 patients (12%) in the edoxaban group and in 21 patients (14%) in the phenprocoumon group (p = 0.84). Uninterrupted OAC with edoxaban appeared to be as safe as uninterrupted OAC with phenprocoumon in patients who underwent LA RF ablation procedures.
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Sugrue A, Siontis KC, Piccini JP, Noseworthy PA. Periprocedural Anticoagulation Management for Atrial Fibrillation Ablation: Current Knowledge and Future Directions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:3. [DOI: 10.1007/s11936-018-0600-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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A Prospective Randomized Trial of Apixaban Dosing During Atrial Fibrillation Ablation: The AEIOU Trial. JACC Clin Electrophysiol 2017; 4:580-588. [PMID: 29798783 DOI: 10.1016/j.jacep.2017.11.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/25/2017] [Accepted: 11/02/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study sought to determine whether uninterrupted apixaban would have similar rates of bleeding and thromboembolic events as does minimally interrupted apixaban at the time of atrial fibrillation (AF) ablation and to compare those results with rates in historical patients treated with uninterrupted warfarin. BACKGROUND The safety, efficacy, and optimal dosing regimen for apixaban at the time of AF ablation are uncertain. METHODS This prospective, multicenter clinical trial enrolled 306 patients undergoing catheter ablation for nonvalvular AF and randomized 300 to uninterrupted versus minimally interrupted (holding 1 dose) periprocedural apixaban. A retrospective cohort of patients treated with uninterrupted warfarin at the same centers was matched to the apixaban-treated subjects for comparison. Endpoints included clinically significant bleeding, major bleeding, and nonhemorrhagic stroke or systemic embolism (SE) from the time of ablation through 30 days. RESULTS There were no stroke or SE events. Clinically significant bleeding occurred in 11.3% of 150 evaluable patients on uninterrupted apixaban and 9.7% of 145 evaluable patients on interrupted apixaban (risk difference: 1.7% [95% confidence interval: -5.5% to 8.8%]; p = NS). Rates of major bleeding were 1.3% with uninterrupted apixaban, and 2.1% with interrupted (risk difference: -0.7%; p = NS). The rates of clinically significant and major bleeding were similar for all apixaban patients combined (10.5% and 1.7%), compared with the matched warfarin group (9.8% and 1.4%). CONCLUSIONS Both uninterrupted and minimally interrupted apixaban at the time of AF ablation were associated with a very low rate of thromboembolic events, and rates of both major (<2%) and clinically significant bleeding were similar to uninterrupted warfarin. (Apixaban Evaluation of Interrupted Or Uninterrupted Anticoagulation for Ablation of Atrial Fibrillation [AEIOU]; NCT02608099).
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Meta-Analysis of Safety and Efficacy of Uninterrupted Non-Vitamin K Antagonist Oral Anticoagulants Versus Vitamin K Antagonists for Catheter Ablation of Atrial Fibrillation. Am J Cardiol 2017; 120:1830-1836. [PMID: 28882334 DOI: 10.1016/j.amjcard.2017.07.096] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/13/2017] [Accepted: 07/20/2017] [Indexed: 12/26/2022]
Abstract
This meta-analysis sought to assess the safety and efficacy of uninterrupted non-vitamin K antagonist oral anticoagulants (NOACs) versus uninterrupted vitamin K antagonists in atrial fibrillation (AF) patients undergoing catheter ablation. Electronic databases were searched for randomized trials (RCTs) and observational studies that compared uninterrupted NOACs versus uninterrupted vitamin K antagonists in the catheter ablation of AF. Safety outcomes included major bleeding, total bleeding, minor bleeding, and cardiac tamponade. Efficacy outcomes were symptomatic thromboembolism and symptomatic stroke/transient ischemic attack. Summary estimate risk ratios (RRs) were constructed primarily with a DerSimonian-Laird model. Thirteen studies (3 RCTs and 10 observational studies) with 4,878 patients were included. The risk of major bleeding (RR 0.83, 95% confidence interval [CI] 0.46 to 1.50, p = 0.53), total bleeding (RR 0.90, 95% CI 0.71 to 1.15, p = 0.41), minor bleeding (RR 0.98, 95% CI 0.80 to 1.21, p = 0.85), cardiac tamponade (RR 0.85, 95% CI 0.43 to 1.69, p = 0.65), symptomatic thromboembolism (RR 0.92, 95% CI 0.26 to 3.31, p = 0.90), and symptomatic stroke/transient ischemic attack (RR 1.03, 95% CI 0.29 to 3.65, p = 0.97) was similar in both groups. The quality of evidence for both major bleeding and symptomatic thromboembolism was moderate for RCTs and very low for observational studies. In conclusion, the use of uninterrupted NOACs in AF catheter ablation appears to be safe and efficacious. The evidence is not of high quality; thus, further high-quality RCTs are needed to confirm these findings.
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Bai Y, Shi XB, Ma CS, Lip GYH. Meta-Analysis of Effectiveness and Safety of Oral Anticoagulants in Atrial Fibrillation With Focus on Apixaban. Am J Cardiol 2017; 120:1689-1695. [PMID: 28844510 DOI: 10.1016/j.amjcard.2017.07.072] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/12/2017] [Accepted: 07/21/2017] [Indexed: 11/18/2022]
Abstract
We performed a meta-analysis of data on the effectiveness and safety of apixaban compared with other oral anticoagulants (warfarin or rivaroxaban or dabigatran or edoxaban) for stroke prevention in atrial fibrillation (AF) in different settings of randomized controlled trials, real-world studies, and radiofrequency ablation (RFA). Thirty studies were searched in PubMed, the Cochrane Library, and Clinicaltrials.gov databases reporting comparative effectiveness and safety of apixaban with warfarin (n = 23), rivaroxaban (n = 12), dabigatran (n = 13), or edoxaban (n = 2) for stroke prevention in AF. In real-world estimates, apixaban was similar to warfarin for the prevention of stroke or systematic thromboembolism (hazard ratio 0.93, 95% CI 0.71 to 1.14, I2 = 82.9%, N = 7), and safer than warfarin in the risks of major bleeding (hazard ratio 0.62, 95% CI 0.54 to 0.70, I2 = 18.7%, N = 9) in patients with AF. The risk of stroke or thromboembolism with apixaban was similar to rivaroxaban, dabigatran, and edoxaban in the settings of real-world studies and RFA. Major bleeding with apixaban was generally lower than rivaroxaban (relative risks 0.45, 95% CI 0.38 to 0.53, I2 = 0%, N = 5) and similar to dabigatran in real-world studies (relative risks 1.44, 95% CI 0.33 to 6.30, I2 = 97.7%, N = 5), but similar to rivaroxaban, dabigatran, and edoxaban in RFA. In conclusion, our meta-analysis provides a comprehensive estimate of the effectiveness and safety of apixaban compared with other oral anticoagulants (warfarin, rivaroxaban, dabigatran, and edoxaban) in patients with AF in different settings of randomized controlled trial, real-world studies, and RFA.
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Affiliation(s)
- Ying Bai
- Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China; Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Xu-Bo Shi
- Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Chang-Sheng Ma
- Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China; Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing 100029, China.
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Yanagisawa S, Inden Y, Fujii A, Ando M, Funabiki J, Murase Y, Takenaka M, Otake N, Ikai Y, Sakamoto Y, Shibata R, Murohara T. Renal function and risk of stroke and bleeding in patients undergoing catheter ablation for atrial fibrillation: Comparison between uninterrupted direct oral anticoagulants and warfarin administration. Heart Rhythm 2017; 15:348-354. [PMID: 29107192 DOI: 10.1016/j.hrthm.2017.10.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND The effect of uninterrupted oral anticoagulant use in patients with chronic kidney disease (CKD) during catheter ablation for atrial fibrillation (AF) is not fully understood. OBJECTIVE The present study aimed to evaluate the safety and efficacy of periprocedural uninterrupted direct oral anticoagulant (DOAC) use compared with those of uninterrupted warfarin use in patients undergoing catheter ablation for AF stratified by various renal function groups. METHODS A total of 2091 patients were retrospectively included in this study. The study population was divided into 4 groups: creatinine clearance level ≥80 mL/min (n = 1086), 50-79 mL/min (n = 774), 15-49 mL/min (n = 209), and <15 mL/min (n = 22). We investigated periprocedural complications and compared them between uninterrupted DOAC and warfarin groups. RESULTS There was no significant difference in thromboembolic events among the 4 groups (0.6%, 0.6%, 1.0%, and 0%, respectively; P = .792). However, major bleeding events (0.9%, 1.4%, 4.8%, and 4.5%; P < .001) and minor bleeding events (4.1%, 6.1%, 11.5%, and 13.6%; P < .001) primarily occurred in patients with CKD. The rate of periprocedural complications in the DOAC group was similar to that in the warfarin group for each renal function category. Adverse events did not differ after adjustment using propensity score-matched analysis. Multivariate analysis showed that lower body weight, antiplatelet drug use, initial ablation session, and CKD were independent predictors of adverse events. CONCLUSION The periprocedural bleeding risk was increased in patients with CKD. Uninterrupted DOAC and warfarin administration during catheter ablation for AF in patients with CKD is feasible and effective.
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Affiliation(s)
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Aya Fujii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Monami Ando
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junya Funabiki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yosuke Murase
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaki Takenaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Noriaki Otake
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiro Ikai
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Sakamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Rei Shibata
- Department of Advanced Cardiovascular Therapeutics, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Laish-Farkash A, Suleiman M. Evaluation of left atrial thrombus prior to catheter ablation of atrial fibrillation: Is it time for an individualized approach? J Cardiovasc Electrophysiol 2017; 28:1137-1139. [DOI: 10.1111/jce.13303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Avishag Laish-Farkash
- Electrophysiology and Pacing Unit, Department of Cardiology; Rambam Health Care Campus; Haifa Israel
| | - Mahmoud Suleiman
- Electrophysiology and Pacing Unit, Department of Cardiology; Rambam Health Care Campus; Haifa Israel
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28
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Brendel LC, Dobler F, Hessling G, Michel J, Braun SL, Steinsiek AL, Groha P, Eckl R, Deisenhofer I, Hyseni A, Roest M, Ott I, Steppich B. The anticoagulant effect of heparin during radiofrequency ablation (RFA) in patients taking apixaban or rivaroxaban. J Interv Card Electrophysiol 2017; 49:237-244. [PMID: 28735423 DOI: 10.1007/s10840-017-0274-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 07/10/2017] [Indexed: 01/09/2023]
Abstract
PURPOSE Measuring the anticoagulant effect of heparin during radiofrequency ablation (RFA) in patients taking apixaban and rivaroxaban is challenging, since the activated coagulation time (ACT) does not seem to reflect the true anticoagulant activity of these drugs. We therefore evaluated coagulation properties of apixaban and rivaroxaban during RFA by different coagulation assays to better monitor periprocedural hemostasis. METHODS The study included 90 patients (61 ± 12 years) with atrial fibrillation who underwent RFA procedures. Patients received 20 mg rivaroxaban (n = 73) once or 5 mg apixaban (n = 17) twice daily 4 weeks prior to the procedure. During RFA, unfractionated heparin i.v. was given to maintain an ACT of 250-300 s. Blood samples were taken before and 10, 60, and 360 min after heparin administration. RESULTS Heparin displayed a lower anti-Xa activity in rivaroxaban-treated patients compared to apixaban-treated patients. In contrast, D-dimer and prothrombin fragment F1+2 plasma levels indicated a higher activation of the coagulation cascade in apixaban/heparin than in rivaroxaban/heparin patients. This discordant coagulative state measured in vitro had no clinical impact in terms of bleeding or thromboembolic complications. CONCLUSION We found different biochemical responses to rivaroxaban/heparin and apixaban/heparin during RFA. Precaution is necessary when monitoring periprocedural hemostasis in DOAC patients to avoid mismanagement.
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Affiliation(s)
- L C Brendel
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - F Dobler
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - G Hessling
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - J Michel
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - S L Braun
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - A L Steinsiek
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - P Groha
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - R Eckl
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - I Deisenhofer
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - A Hyseni
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Roest
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Ott
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - B Steppich
- Deutsches Herzzentrum der Technischen Universität München, Lazarettstr. 36, 80636, Munich, Germany.
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Steppich B, Dobler F, Brendel LC, Hessling G, Braun SL, Steinsiek AL, Deisenhofer I, Hyseni A, Roest M, Ott I. Effect of the FXa inhibitors Rivaroxaban and Apixaban on platelet activation in patients with atrial fibrillation. J Thromb Thrombolysis 2017; 43:490-497. [DOI: 10.1007/s11239-017-1495-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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30
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New oral anticoagulants compared to warfarin for perioperative anticoagulation in patients undergoing atrial fibrillation catheter ablation: a meta-analysis of continuous or interrupted new oral anticoagulants during ablation compared to interrupted or continuous warfarin. J Interv Card Electrophysiol 2017; 48:267-282. [DOI: 10.1007/s10840-016-0221-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 12/19/2016] [Indexed: 12/11/2022]
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Garg J, Chaudhary R, Krishnamoorthy P, Shah N, Bozorgnia B, Natale A. Safety And Efficacy Of Uninterrupted Periprocedural Apixaban In Patients Undergoing Atrial Fibrillation Catheter Ablation: A Metaanalysis Of 1,057 Patients. J Atr Fibrillation 2016; 8:1368. [PMID: 27909496 DOI: 10.4022/jafib.1368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 04/11/2016] [Accepted: 04/11/2016] [Indexed: 11/10/2022]
Abstract
Apixaban (factor Xa inhibitor) is a novel anticoagulant and may be beneficial during atrial fibrillation (AF) ablation for prevention of thromboembolic events. However, the adverse effects of periprocedural apixaban therapy have not been thoroughly evaluated. A meta-analysis was performed to evaluate the safety of apixaban for anticoagulation in AF ablation. We searched the online databases till October 2015 for studies comparing Apixaban with Vitamin K antagonists in atrial fibrillation patients undergoing catheter ablation. Primary outcome of our study was composite of thromboembolic event and bleeding (includes major and minor bleeding). A total of 1,057 atrial fibrillation patients in 3 studies undergoing catheter ablation were included in this analysis. Zero thromboembolic events were reported in the apixaban group and 1 in the VKA group with no statistical difference (OR 0.75; 95% CI 0.03-18.49). No major differences were observed for the primary outcome (OR 0.92; 95% CI 0.54-1.55), risk of overall bleeding (OR 0.94, 95% CI 0.55- 1.58), major bleeding (OR1.37; 95% CI 0.33-5.67), minor bleeding (OR 0.89; 95% CI 0.50-1.55), pericardial effusion (OR 0.50; 95% CI 0.18-1.38) and groin hematoma (OR 1.36; 95% CI 0.70-2.65). Uninterrupted apixaban administration in patients undergoing AF catheter ablation was non-inferior to VKA without increasing the risk of major and minor bleeding.
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Affiliation(s)
- Jalaj Garg
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA
| | - Rahul Chaudhary
- Department of Medicine, Sinai Hospital of Baltimore, Johns Hopkins University, Baltimore, MD
| | | | - Neeraj Shah
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA
| | - Babak Bozorgnia
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX
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32
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Meta-analysis of efficacy and safety of apixaban and uninterrupted apixaban therapy compared to vitamin K antagonists in patients undergoing catheter ablation for atrial fibrillation. J Interv Card Electrophysiol 2016; 48:223-233. [DOI: 10.1007/s10840-016-0195-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 10/02/2016] [Indexed: 11/26/2022]
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33
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Di Biase L, Callans D, Hæusler KG, Hindricks G, Al-Khalidi H, Mont L, Cosedis Nielsen J, Piccini JP, Schotten U, Kirchhof P. Rationale and design of AXAFA-AFNET 5: an investigator-initiated, randomized, open, blinded outcome assessment, multi-centre trial to comparing continuous apixaban to vitamin K antagonists in patients undergoing atrial fibrillation catheter ablation. Europace 2016; 19:132-138. [DOI: 10.1093/europace/euw368] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 10/14/2016] [Indexed: 11/12/2022] Open
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34
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4738] [Impact Index Per Article: 592.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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35
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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36
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1318] [Impact Index Per Article: 164.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
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Gunawardene M, Willems S, Schäffer B, Moser J, Akbulak RÖ, Jularic M, Eickholt C, Nührich J, Meyer C, Kuklik P, Sehner S, Czerner V, Hoffmann BA. Influence of periprocedural anticoagulation strategies on complication rate and hospital stay in patients undergoing catheter ablation for persistent atrial fibrillation. Clin Res Cardiol 2016; 106:38-48. [PMID: 27435077 DOI: 10.1007/s00392-016-1021-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/08/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND The use of non-vitamin K antagonists (NOACs), uninterrupted (uVKA) and interrupted vitamin K antagonists (iVKA) are common periprocedural oral anticoagulation (OAC) strategies for atrial fibrillation (AF) ablation. Comparative data on complication rates resulting from OAC strategies for solely persistent AF (persAF) undergoing ablation are sparse. Thus, we sought to determine the impact of these OAC strategies on complication rates among patients with persAF undergoing catheter ablation. METHODS Consecutive patients undergoing persAF ablation were included. Depending on preprocedural OAC, three groups were defined: (1) NOACs (paused 48 h preablation), (2) uVKA, and (3) iVKA with heparin bridging. A combined complication endpoint (CCE) composed of bleeding and thromboembolic events was analyzed. RESULTS Between 2011 and 2014, 1440 persAF ablation procedures were performed in 1092 patients. NOACs were given in 441 procedures (31 %; rivaroxaban 57 %, dabigatran 33 %, and apixaban 10 %), uVKA in 488 (34 %), and iVKA in 511 (35 %). Adjusted CCE rates were 5.5 % [95 % confidence interval (CI) (3.1-7.8)] in group 1 (NOACs), 7.5 % [95 % CI (5.0-10.1)] in group 2 (uVKA), and 9.9 % [95 % CI (6.6-13.2)] in group 3. Compared to group 1, the combined complication risk was almost twice as high in group 3 [odd's ratio (OR) 1.9, 95 % CI (1.0-3.7), p = 0.049)]. The major complication rate was low (0.9 %). Bleeding complications, driven by minor groin complications, are more frequent than thromboembolic events (n = 112 vs. 1, p < 0.0001). CONCLUSIONS Patients undergoing persAF ablation with iVKA anticoagulation have an increased risk of complications compared to NOACs. Major complications, such as thromboembolic events, are generally rare and are exceeded by minor bleedings.
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Affiliation(s)
- Melanie Gunawardene
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany.
| | - S Willems
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - B Schäffer
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - J Moser
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - R Ö Akbulak
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - M Jularic
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - C Eickholt
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - J Nührich
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - C Meyer
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - P Kuklik
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - S Sehner
- Institute for Medical Biometry and Epidemiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - V Czerner
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - B A Hoffmann
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
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Abed HS, Chen V, Kilborn MJ, Sy RW. Periprocedural Management of Novel Oral Anticoagulants During Atrial Fibrillation Ablation: Controversies and Review of the Current Evidence. Heart Lung Circ 2016; 25:1164-1176. [PMID: 27425183 DOI: 10.1016/j.hlc.2016.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 04/05/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
Abstract
Oral anticoagulation (OAC) has been the cornerstone for the prevention of thromboembolic complications in patients with atrial fibrillation (AF) at significant risk of stroke. Catheter ablation is an established efficacious technique for the treatment of AF. Ameliorating the risk of stroke or transient ischaemic attack (TIA) in patients with AF undergoing ablation requires meticulous planning of pharmacotherapy. The advent of non-vitamin K oral anticoagulants (NOACs) has broadened the therapeutic scope, representing a viable alternative to traditional vitamin K antagonists (VKA) in non-valvular AF. Potential advantages of NOACs include greater pharmacokinetic predictability, at least comparable efficacy as compared to VKA and a superior haemorrhagic complication profile. However, robust evidence for the safety and efficacy of periprocedural NOAC use for AF ablation remains uncertain with a non-uniform clinical approach between and within institutions. The following review will summarise the current and emerging evidence on periprocedural management of NOACs in patients undergoing catheter ablation of AF. An overview of NOAC pharmacology will provide a foundation for the review of reversal agents in the context of catheter ablation of AF. The purpose of the review is to outline key studies and identify key areas for further critical research with the ultimate aim of developing evidence-based guidelines for optimal care.
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Affiliation(s)
- Hany S Abed
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, NSW, Australia
| | - Vivien Chen
- Department of Haematology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, NSW, Australia
| | - Michael J Kilborn
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, NSW, Australia.
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Uninterrupted New Oral Anticoagulants Compared With Uninterrupted Vitamin K Antagonists in Ablation of Atrial Fibrillation: A Meta-analysis. Can J Cardiol 2016; 32:814-23. [PMID: 26810476 DOI: 10.1016/j.cjca.2015.09.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/18/2015] [Accepted: 09/20/2015] [Indexed: 11/23/2022] Open
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40
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Blandino A, Bianchi F, Biondi-Zoccai G, Grossi S, Conte MR, Rametta F, Gaita F. Apixaban for periprocedural anticoagulation during catheter ablation of atrial fibrillation: a systematic review and meta-analysis of 1691 patients. J Interv Card Electrophysiol 2016; 46:225-36. [PMID: 27217030 DOI: 10.1007/s10840-016-0141-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/27/2016] [Indexed: 02/08/2023]
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BRICENO DAVIDF, VILLABLANCA PEDROA, LUPERCIO FLORENTINO, KARGOLI FARAJ, JAGANNATH ANAND, LONDONO ALEJANDRA, PATEL JIGNESH, OTUSANYA OLUFISAYO, BREVIK JEANNINE, MARABOTO CAROLA, BERARDI CECILIA, KRUMERMAN ANDREW, PALMA EUGEN, KIM SOOG, NATALE ANDREA, DI BIASE LUIGI. Clinical Impact of Heparin Kinetics During Catheter Ablation of Atrial Fibrillation: Meta-Analysis and Meta-Regression. J Cardiovasc Electrophysiol 2016; 27:683-93. [DOI: 10.1111/jce.12975] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 03/08/2016] [Accepted: 03/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- DAVID F. BRICENO
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - PEDRO A. VILLABLANCA
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - FLORENTINO LUPERCIO
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - FARAJ KARGOLI
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - ANAND JAGANNATH
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - ALEJANDRA LONDONO
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - JIGNESH PATEL
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - OLUFISAYO OTUSANYA
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - JEANNINE BREVIK
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - CAROLA MARABOTO
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - CECILIA BERARDI
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - ANDREW KRUMERMAN
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - EUGEN PALMA
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - SOO G. KIM
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
| | - ANDREA NATALE
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
- Department of Biomedical Engineering; University of Texas; Austin Texas USA
- Division of Cardiology; Stanford University; Palo Alto California USA
- Case Western Reserve University; Cleveland Ohio USA
- Scripps Clinic; San Diego California USA. Dell Medical School; Austin Texas USA. California Pacific Medical Center; San Francisco California USA. Department of Cardiology; University of Foggia; Foggia Italy
| | - LUIGI DI BIASE
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center; Albert Einstein College of Medicine; New York New York USA
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
- Department of Biomedical Engineering; University of Texas; Austin Texas USA
- Department of Cardiology; University of Foggia; Foggia Italy
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Spyropoulos AC, Al-Badri A, Sherwood MW, Douketis JD. Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery. J Thromb Haemost 2016; 14:875-85. [PMID: 26988871 DOI: 10.1111/jth.13305] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 02/10/2016] [Indexed: 11/28/2022]
Abstract
The periprocedural management of patients receiving chronic therapy with oral anticoagulants (OACs), including vitamin K antagonists (VKAs) such as warfarin and direct OACs (DOACs), is a common clinical problem. The optimal perioperative management of patients receiving chronic OAC therapy is anchored on four key principles: (i) risk stratification of patient-related and procedure-related risks of thrombosis and bleeding; (ii) the clinical consequences of a thrombotic or bleeding event; (iii) discontinuation and reinitiation of OAC therapy on the basis of the pharmacokinetic properties of each agent; and (iv) whether aggressive management such as the use of periprocedural heparin bridging has advantages for the prevention of postoperative thromboembolism at the cost of a possible increase in bleeding risk. Recent data from randomized trials in patients receiving VKAs undergoing pacemaker/defibrillator implantation or using heparin bridging therapy for elective procedures or surgeries can now inform best practice. There are also emerging data on periprocedural outcomes in the DOAC trials for patients with non-valvular atrial fibrillation. This review summarizes the evidence for the periprocedural management of patients receiving chronic OAC therapy, focusing on recent randomized trials and large outcome studies, to address three key clinical scenarios: (i) can OAC therapy be safely continued for minor procedures or surgeries; (ii) if therapy with VKAs (especially warfarin) needs to be temporarily interrupted for an elective procedure/surgery, is heparin bridging necessary; and (iii) what is the optimal periprocedural management of the DOACs? In answering these questions, we aim to provide updated clinical guidance for the periprocedural management of patients receiving VKA or DOAC therapy, including the use of heparin bridging.
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Affiliation(s)
- A C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra North Shore/LIJ School of Medicine, North Shore/LIJ Health System, Manhasset, NY, USA
| | - A Al-Badri
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - M W Sherwood
- Durham VA Medical Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - J D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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43
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Li PJ, Xiao J, Yang Q, Feng Y, Wang T, Liu GJ, Liang ZA. Network meta-analysis of efficacy and safety of competitive oral anticoagulants in patients undergoing radiofrequency catheter ablation of atrial fibrillation. J Interv Card Electrophysiol 2016; 46:213-24. [PMID: 27001171 DOI: 10.1007/s10840-016-0126-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 03/07/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this network meta-analysis was to evaluate the comparative efficacy and safety of dabigatran, rivaroxaban, apixaban, interrupted vitamin K antagonist (I-VKA), and continuous VKA (C-VKA) in patients undergoing radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). METHODS PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to identify clinical trials comparing dabigatran, rivaroxaban, or apixaban with I-VKA or C-VKA, or against each other, in AF patients undergoing RFCA. A network meta-analysis was conducted to directly and indirectly compare the efficacy and safety of competitive anticoagulation regimens with a Bayesian random-effects model. RESULTS A total of 39 studies enrolling 27,766 patients were included. C-VKA demonstrated significant superiority over I-VKA in reducing thromboembolic events (risk difference [RD] -0.0068, 95 % confidence interval [CI] -0.0106 to -0.0032) and major bleeding complications (RD -0.0044, 95 % CI -0.0098 to -0.0006). Rivaroxaban compared with I-VKA was associated with a lower risk of thromboembolism (RD -0.0073, 95 % CI -0.0134 to -0.0012), being at the best ranking position among all of the compared anticoagulation regimens in terms of both the efficacy and safety. None of the remaining comparisons reached statistically significant difference in the rate of thromboembolism or major bleeding. CONCLUSIONS The present study suggests that C-VKA is superior to I-VKA for AF patients undergoing RFCA. Rivaroxaban is the highest probability to be the optimal alternative to C-VKA among the three non-VKA oral anticoagulants in AF ablation.
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Affiliation(s)
- Pei-Jun Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, Sichuan, People's Republic of China, 610041
| | - Jun Xiao
- Department of Intensive Care Unit, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Qing Yang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Yuan Feng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Ting Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, Sichuan, People's Republic of China, 610041
| | - Guan-Jian Liu
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Zong-An Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, Sichuan, People's Republic of China, 610041.
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Wu S, Yang YM, Zhu J, Wan HB, Wang J, Zhang H, Shao XH. Meta-Analysis of Efficacy and Safety of New Oral Anticoagulants Compared With Uninterrupted Vitamin K Antagonists in Patients Undergoing Catheter Ablation for Atrial Fibrillation. Am J Cardiol 2016; 117:926-34. [PMID: 26803384 DOI: 10.1016/j.amjcard.2015.12.027] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/16/2015] [Accepted: 12/16/2015] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Shuang Wu
- Emergency and Intensive Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yan-min Yang
- Emergency and Intensive Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Jun Zhu
- Emergency and Intensive Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Huai-bin Wan
- Emergency and Intensive Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Juan Wang
- Emergency and Intensive Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Han Zhang
- Emergency and Intensive Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xing-hui Shao
- Emergency and Intensive Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Gianni C, DI Biase L, Mohanty S, Trivedi C, Bai R, Al-Ahmad A, Burkhardt JD, Gallinghouse GJ, Horton RP, Sanchez JE, Hranitzky PM, Lakkireddy D, Mansour MC, Santangeli P, Zado ES, Marchlinski FE, Beheiry S, Hao SC, Couts L, Gibson D, Natale A. Management of Periprocedural and Early Pericardial Effusions With Tamponade Following Ablation of Atrial Fibrillation With Uninterrupted Factor Xa Inhibitors: A Case Series. J Cardiovasc Electrophysiol 2016; 27:399-403. [PMID: 26756289 DOI: 10.1111/jce.12918] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/22/2015] [Accepted: 11/25/2015] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Because of the absence of a dedicated reversal agent, the outcome of pericardial effusion (PE) following procedures performed with uninterrupted apixaban or rivaroxaban is unknown. We report the characteristics of PEs presenting with tamponade in patients undergoing AF ablation with uninterrupted factor Xa inhibition (FXaI) to understand their management and prognosis. METHODS AND RESULTS We performed a multicenter cross-sectional survey in 10 centers across the United States. Patient data were obtained by chart review. In all patients the procedure was performed with uninterrupted FXaI. A total of 16 PEs requiring intervention were reported from 5 centers. Two patients were on apixaban 5 mg BD, the remaining on rivaroxaban 20 mg OD. Eleven PEs occurred in the periprocedural setting, and 5 PEs occurred from 1 to 28 days after the procedure. Pericardiocentesis and drainage were performed in all cases. Protamine and 4-factor prothrombin complex concentrate (4F-PCC) were given in all periprocedural cases. Two patients required surgery: in one case coagulation of the pericardial blood prevented effective drainage, and in the other bleeding was secondary to a steam pop-induced atrial tear. None of the postprocedural cases required FXaI reversal and the dose of rivaroxaban was temporarily reduced. No fatal outcomes or thromboembolic events were reported. CONCLUSION Pericardiocentesis and drainage with FXaI reversal proved effective in the management of acute PEs with tamponade occurring periprocedurally in patients undergoing AF ablation with uninterrupted FXaI. Early postprocedural effusions can be treated with pericardiocentesis without the need of a reversal agent.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luigi DI Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Biomedical Engineering, University of Texas, Austin, Texas, USA.,Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Rong Bai
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | | | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.,Department of Biomedical Engineering, University of Texas, Austin, Texas, USA
| | - Javier E Sanchez
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Patrick M Hranitzky
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Moussa C Mansour
- Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica S Zado
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Salwa Beheiry
- Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, California, USA
| | - Steven C Hao
- Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, California, USA
| | - Linda Couts
- Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA
| | - Douglas Gibson
- Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Biomedical Engineering, University of Texas, Austin, Texas, USA.,Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, California, USA.,Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA.,MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Division of Cardiology, Stanford University, Stanford, California, USA.,Dell Medical School, University of Texas, Austin, Texas, USA
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Nakamura K, Naito S, Sasaki T, Minami K, Take Y, Goto E, Shimizu S, Yamaguchi Y, Suzuki N, Yano T, Senga M, Kumagai K, Kaseno K, Funabashi N, Oshima S. Silent Cerebral Ischemic Lesions After Catheter Ablation of Atrial Fibrillation in Patients on 5 Types of Periprocedural Oral Anticoagulation – Predictors of Diffusion-Weighted Imaging-Positive Lesions and Follow-up Magnetic Resonance Imaging –. Circ J 2016; 80:870-7. [DOI: 10.1253/circj.cj-15-1368] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Eri Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Satoru Shimizu
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | | | - Naoko Suzuki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Toshiaki Yano
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Michiharu Senga
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Koji Kumagai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kenichi Kaseno
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine
| | - Shigeru Oshima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
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Lu D, Liu Q, Wang K, Zhang QI, Shan QJ. Meta-Analysis of Efficacy and Safety of Apixaban in Patients Undergoing Catheter Ablation for Atrial Fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 39:54-9. [PMID: 26495799 DOI: 10.1111/pace.12771] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/04/2015] [Accepted: 10/07/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND The efficacy and safety of apixaban in patients undergoing catheter ablation (CA) for atrial fibrillation (AF) are little investigated. METHODS The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE were searched up to September 2015. Four literatures comparing apixaban with vitamin K antagonists (VKAs) were included. Data were pooled in Review Manager Software, using Mantel-Haenszel methods with a fixed-effects model. The funnel plots and Egger's test were used to examine publication bias. Heterogeneity was assessed using the I(2) test. Risk ratios (RR) and 95% confidence intervals (CI) of each study were calculated and pooled. RESULTS No significant differences were observed in rates of total bleeding (RR = 0.91, 95% CI [0.57, 1.46], I(2) = 0.0%), thromboembolic complications (RR = 0.75, 95% CI [0.03, 18.22], I(2) = 0.0%), or total events (RR = 0.90, 95% CI [0.56, 1.44], I(2) = 0.0%) between apixaban and VKAs group. The frequency of major bleeding was similar between apixaban and VKAs group (RR = 1.34, 95% CI [0.34, 5.30], I(2) = 0.0%). CONCLUSION Apixaban was as effective and safe as VKAs in the periprocedural period of CA.
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Affiliation(s)
- Dasheng Lu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.,Department of Cardiology, The Second Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Qian Liu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Kai Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Q I Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Qi-Jun Shan
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Bleeding risks with novel oral anticoagulants during catheter ablation of atrial fibrillation: a systematic review and network meta-analysis. J Interv Card Electrophysiol 2015; 44:105-11. [PMID: 26342485 DOI: 10.1007/s10840-015-0053-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/26/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Comprehensive comparisons of safety (measured by bleeding risk) between multiple novel oral anticoagulants (NOACs and warfarin) in the peri-procedural period of catheter ablation (CA) for atrial fibrillation (AF) are rare. METHODS AND RESULTS MEDLINE, EMBASE, and COCHRANE LIBRARY were searched up to February 2015 by two reviewers independently. Predefined inclusion criteria identified 24 studies which were included in the analysis. Data were extracted by two researchers, and a network meta-analysis was conducted in R with R2WinBugS package, within Bayesian framework. Pooled odds ratios (OR) and 95% confidence intervals (CI) were summarized to evaluate the bleeding risks of three novel anticoagulants (dabigatran, rivaroxaban, apixaban) in AF patients undergoing catheter ablation (CA). With respect to total bleeding risk, no significant difference was observed between dabigatran, rivaroxaban, apixaban, and vitamin K antagonists (VKAs) by mixed-treatment comparison. The similar results were seen in the direct comparison. While dabigatran was associated with a lower rate of minor bleeding in comparison to VKAs (OR = 0.67 with 95%CI 0.49-0.93). CONCLUSIONS Risks of bleeding with dabigatran, rivaroxaban, apixaban, and VKAs were similar in peri-procedural period of CA for AF.
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Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17:1467-507. [PMID: 26324838 DOI: 10.1093/europace/euv309] [Citation(s) in RCA: 723] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 02/10/2015] [Indexed: 12/24/2022] Open
Abstract
The current manuscript is an update of the original Practical Guide, published in June 2013[Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-51; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-106]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with non-valvular atrial fibrillation (AF). Both physicians and patients have to learn how to use these drugs effectively and safely in clinical practice. Many unresolved questions on how to optimally use these drugs in specific clinical situations remain. The European Heart Rhythm Association set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group defined what needs to be considered as 'non-valvular AF' and listed 15 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 15 topics are (i) practical start-up and follow-up scheme for patients on NOACs; (ii) how to measure the anticoagulant effect of NOACs; (iii) drug-drug interactions and pharmacokinetics of NOACs; (iv) switching between anticoagulant regimens; (v) ensuring adherence of NOAC intake; (vi) how to deal with dosing errors; (vii) patients with chronic kidney disease; (viii) what to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a risk of bleeding?; (xi) management of bleeding complications; (x) patients undergoing a planned surgical intervention or ablation; (xi) patients undergoing an urgent surgical intervention; (xii) patients with AF and coronary artery disease; (xiii) cardioversion in a NOAC-treated patient; (xiv) patients presenting with acute stroke while on NOACs; and (xv) NOACs vs. VKAs in AF patients with a malignancy. Additional information and downloads of the text and anticoagulation cards in >16 languages can be found on an European Heart Rhythm Association web site (www.NOACforAF.eu).
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Effect of pre-procedural interrupted apixaban on heparin anticoagulation during catheter ablation for atrial fibrillation: a prospective observational study. J Interv Card Electrophysiol 2015; 44:91-6. [DOI: 10.1007/s10840-015-0048-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/12/2015] [Indexed: 10/23/2022]
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