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Shinohara T, Takahashi N, Mukai Y, Kimura T, Yamaguchi K, Takita A, Origasa H, Okumura K. Changes in plasma concentrations of edoxaban and coagulation biomarkers according to thromboembolic risk and atrial fibrillation type in patients undergoing catheter ablation: Subanalysis of KYU-RABLE. J Arrhythm 2021; 37:70-78. [PMID: 33664888 PMCID: PMC7896453 DOI: 10.1002/joa3.12490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/18/2020] [Accepted: 12/09/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Catheter ablation (CA) for atrial fibrillation (AF) can be associated with a risk of thromboembolism and bleeding. We recently demonstrated that uninterrupted edoxaban with one dose delayed on the CA procedural day is associated with a low risk of periprocedural complications. Previous reports have indicated that some specific subgroups of patients undergoing CA have an increased risk of bleeding and thromboembolic complications. This subanalysis of the KYU-RABLE study assessed the changes in plasma concentrations of edoxaban and coagulation biomarkers during the periprocedural period of CA in subgroups stratified by the risk of thromboembolism assessed by CHADS2 score (<2 or ≥2) and AF type (paroxysmal AF [PAF] or non-PAF). METHODS We evaluated changes in plasma concentrations of edoxaban and coagulation biomarkers (D-dimer and prothrombin fragment F1+2), by subgroup, during the periprocedural period of CA. Measurements were made prior to CA (procedure day). RESULTS This subanalysis evaluated data from 343 patients with CHADS2 score <2 and 134 patients with CHADS2 score ≥2, and from 280 patients with PAF and 197 patients with non-PAF. Plasma edoxaban concentration decreased with time on the day of CA, while plasma concentrations of coagulation biomarkers remained unchanged. No significant differences were observed according to CHADS2 score or type of AF. CONCLUSIONS The changes in plasma concentrations of edoxaban and coagulation biomarkers in each subgroup were similar to those of the whole analysis, regardless of the thromboembolic risk (CHADS2 <2 or ≥2) or AF type (PAF or non-PAF).
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Affiliation(s)
- Tetsuji Shinohara
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Yasushi Mukai
- Cardiology DivisionJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Tetsuya Kimura
- Medical Science DepartmentDaiichi Sankyo Co., LtdTokyoJapan
| | | | - Atsushi Takita
- Data Intelligence DepartmentDaiichi Sankyo Co., LtdTokyoJapan
| | - Hideki Origasa
- Division of Biostatistics and Clinical EpidemiologyUniversity of Toyama Graduate School of Medicine and Pharmaceutical SciencesToyamaJapan
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto Hospital Cardiovascular CenterKumamotoJapan
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Pillarisetti J, Reddy M, Vodapally M, Annapureddy T, Molugu M, Atkins D, Bommana S, Pimentel R, Dendi R, Lakkireddy D. Comparison of peri-procedural anticoagulation with rivaroxaban and apixaban during radiofrequency ablation of atrial fibrillation. Indian Pacing Electrophysiol J 2020; 20:261-264. [PMID: 32810538 PMCID: PMC7691779 DOI: 10.1016/j.ipej.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 07/27/2020] [Accepted: 08/10/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Prospective studies on rivaroxaban and apixaban have shown the safety and efficacy of direct anticoagulation agents (DOAC)s used peri-procedurally during radiofrequency ablation (RFA) of atrial fibrillation (AF). Studies comparing the two agents have not been performed. METHODS Consecutive patients from a prospective registry who underwent RFA of AF between April 2012 and March 2015 and were on apixaban or rivaroxaban were studied. Clinical variables and outcomes were noted. RESULTS There were a total of 358 patients (n = 56 on apixaban and n = 302 on rivaroxaban). There were no differences in baseline characteristics between both groups. The last dose of rivaroxaban was administered the night before the procedure in 96% of patients. In patients on apixaban, 48% of patients whose procedure was in the afternoon took the medication on the morning of the procedure. TIA/CVA occurred in 2 patients (0.6%) in rivaroxaban group with none in apixaban group (p = 0.4). There was no difference in the rate of pericardial effusion between apixaban and rivaroxaban groups [1.7% vs 0.6% (p = 0.4)]. Five percent of patients in both groups had groin complications (p = 0.9). In apixaban group, all groin complications were small hematomas except one patient who had a pseudoaneurysm (1.6%). One pseudo-aneurysm, 1 fistula and 3 large hematomas were noted in patients on rivaroxaban (1.7%) with the rest being small hematomas. DOACs were restarted post procedure typically 4 h post hemostasis. CONCLUSIONS Peri-procedural uninterrupted use of apixaban and rivaroxaban during AF RFA is safe and there are no major differences between both groups.
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Affiliation(s)
| | - Madhu Reddy
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Mamatha Vodapally
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Tulasi Annapureddy
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Maruthsakhi Molugu
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Donita Atkins
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Sudharani Bommana
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Rhea Pimentel
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Raghuveer Dendi
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
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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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Naito K, Nakano M, Iwasa A, Maeno Y, Shintani Y, Yamakawa T, Miyashita K, Oyama K, Nakai D, Katagiri M, Kido H, Masuda S, Kohashi K, Kawamata T, Tanimoto S, Masuda N, Ogata N, Isshiki T. Safety and efficacy of uninterrupted treatment with edoxaban or warfarin during the peri-procedural period of catheter ablation for atrial fibrillation. J Arrhythm 2020; 36:634-641. [PMID: 32782633 PMCID: PMC7411202 DOI: 10.1002/joa3.12351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/22/2020] [Accepted: 04/06/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The real-world safety and efficacy of uninterrupted anticoagulation treatment with edoxaban (EDX) or warfarin (WFR) during the peri-procedural period of catheter ablation (CA) for atrial fibrillation (AF) are yet to be investigated. METHODS We conducted a two-center experience, observational study to retrospectively investigate consecutive patients who underwent CA for AF and received EDX or WFR. We examined the incidence of thromboembolic and bleeding complications during the peri-procedural period. RESULTS The EDX and WFR groups included 153 and 103 patients, respectively (total: 256 patients). Demise or thromboembolic events did not occur in either of the groups. The incidence of major bleeding in the EDX and WFR groups was 0.7% and 2.9%, respectively. The total incidence of major/minor bleeding in the EDX and WFR groups was 7.8% and 8.7%, respectively. Of note, the incidence of bleeding complications in the uninterrupted WFR strategy group was markedly high in patients with an estimated glomerular filtration rate (eGFR) <30 (75%) or a HAS-BLED score ≥3 (60%). Patients with eGFR ≥30 and a HAS-BLED score ≤2 had a lower incidence of bleeding (<10%), regardless of the administered anticoagulation drug (EDX or WFR). CONCLUSIONS This study confirmed the safety and efficacy of uninterrupted anticoagulation therapy using EDX or WFR in real-world patients undergoing CA for AF. Patients with severely impaired renal function and/or a higher bleeding risk during uninterrupted therapy with WFR were at a prominent risk of bleeding. Therefore, particular attention should be paid in the treatment of these patients.
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Affiliation(s)
- Kazuya Naito
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Masataka Nakano
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Atsushi Iwasa
- Department of CardiologyNew Tokyo HospitalChibaJapan
| | - Yoshio Maeno
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | | | - Takeshi Yamakawa
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Kotaro Miyashita
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Keishiro Oyama
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Daisuke Nakai
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Masaya Katagiri
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Hideaki Kido
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | | | - Keiichi Kohashi
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Tetsuya Kawamata
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Shuzou Tanimoto
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Naoki Masuda
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Nobuhiko Ogata
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
| | - Takaaki Isshiki
- Department of CardiologyAgeo Central General HospitalSaitamaJapan
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Maury P, Belaid S, Ribes A, Voglimacci‐Stephanopoli Q, Mondoly P, Blaye M, Mandel F, Monteil B, Carrié D, Galinier M, Bongard V, Rollin A, Voisin S. Coagulation and heparin requirements during ablation in patients under oral anticoagulant drugs. J Arrhythm 2020; 36:644-651. [PMID: 32782635 PMCID: PMC7411209 DOI: 10.1002/joa3.12357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/13/2020] [Accepted: 04/22/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Anticoagulation during catheter ablation should be closely monitored with activated clotting time (ACT). However vitamin K antagonists (VKA) or direct oral anticoagulant drugs (DOAC) may act differently on ACT and on heparin needs. The aim of this study was to compare ACT and heparin requirements during catheter ablation under various oral anticoagulant drugs and in controls. METHODS Sixty consecutive patients referred for ablation were retrospectively included: group I (n = 15, VKA), group 2 (n = 15, uninterrupted rivaroxaban), group 3 (n = 15, uninterrupted apixaban), and group 4 (n = 15, controls). Heparin requirements and ACT were compared throughout the procedure. RESULTS Heparin requirements during the procedure were significantly lower in patients under VKA compared to DOAC, but similar between DOAC patients and controls.Activated clotting time values were significantly higher in patients under VKA compared to DOAC and similar in DOAC patients versus controls. Furthermore, anticoagulation control as evaluated by the number/proportion of ACT> 300 as well as the time passed over 300 seconds was significantly better in patients under VKA versus DOAC, without significant differences between DOAC and controls. Finally, the number of patients/ACT with excessive ACT values was significantly higher in VKA versus DOAC patients versus controls.There was no significant difference between rivaroxaban and apixaban for ACT or heparin dosing throughout the procedure. CONCLUSION Vitamin K antagonists allowed less heparin requirement despite reaching higher ACT values and more efficient anticoagulation control (with more excessive values) compared to patients under DOAC therapy and to controls. There was no difference in heparin requirements or ACT between DOAC patients and controls.
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Affiliation(s)
- Philippe Maury
- Department of CardiologyUniversity Hospital RangueilToulouseFrance
- Unité INSERM U 1048ToulouseFrance
| | - Slimane Belaid
- Department of CardiologyUniversity Hospital RangueilToulouseFrance
| | - Agnès Ribes
- Hematology laboratoryUniversity Hospital RangueilToulouseFrance
| | | | - Pierre Mondoly
- Department of CardiologyUniversity Hospital RangueilToulouseFrance
| | - Marie Blaye
- Department of CardiologyUniversity Hospital RangueilToulouseFrance
| | - Franck Mandel
- Department of CardiologyUniversity Hospital RangueilToulouseFrance
| | - Benjamin Monteil
- Department of CardiologyUniversity Hospital RangueilToulouseFrance
| | - Didier Carrié
- Department of CardiologyUniversity Hospital RangueilToulouseFrance
| | - Michel Galinier
- Department of CardiologyUniversity Hospital RangueilToulouseFrance
| | - Vanina Bongard
- Department of CardiologyUniversity Hospital RangueilToulouseFrance
- USMR (Unité de Soutien méthodologique à la recherche)University Hospital RangueilToulouseFrance
- UMR 1027INSERM‐Université Toulouse 3France
| | - Anne Rollin
- Department of CardiologyUniversity Hospital RangueilToulouseFrance
| | - Sophie Voisin
- Hematology laboratoryUniversity Hospital RangueilToulouseFrance
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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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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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Differences in prothrombotic response between the uninterrupted and interrupted apixaban therapies in patients undergoing cryoballoon ablation for paroxysmal atrial fibrillation: a randomized controlled study. Heart Vessels 2019; 34:1533-1541. [DOI: 10.1007/s00380-019-01370-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 03/01/2019] [Indexed: 01/24/2023]
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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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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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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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12
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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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13
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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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14
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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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15
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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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16
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Ioannou A, Tsappa I, Metaxa S, Missouris CG. Non-valvular atrial fibrillation: impact of apixaban on patient outcomes. PATIENT-RELATED OUTCOME MEASURES 2017; 8:121-131. [PMID: 29138609 PMCID: PMC5680948 DOI: 10.2147/prom.s117549] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Atrial fibrillation is the most common arrhythmia worldwide, and carries a significantly increased risk of thromboembolic stroke. Initially, vitamin K antagonists were used as stroke prophylaxis; but more recently, a group of drugs known as novel oral anticoagulants have been developed. Apixaban belongs to this group of drugs, and is a factor Xa inhibitor that has emerged as a popular pharmacological agent worldwide. In this review, we will provide an overview of the pivotal trials in the development of apixaban, while also critically evaluating the new emerging real-world data, and discussing the effectiveness, safety, economic viability and future prospects of apixaban and how it impacts on patient outcomes in those with non-valvular atrial fibrillation.
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Affiliation(s)
- Adam Ioannou
- Cardiology Department, Royal Free NHS Foundation Trust, London, UK
| | - Irene Tsappa
- Cardiology Department, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Sofia Metaxa
- Cardiology Department, Frimley Health NHS Foundation Trust, London, UK
| | - Constantinos G Missouris
- Cardiology Department, Medical School, University of Cyprus, Nicosia, Cyprus.,Cardiology Department, Frimley Health NHS Foundation Trust, London, UK
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17
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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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18
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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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19
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Mukai Y, Wada K, Miyamoto K, Nakagita K, Fujimoto M, Hosomi K, Kuwahara T, Takada M, Kusano K, Oita A. The influence of residual apixaban on bleeding complications during and after catheter ablation of atrial fibrillation. J Arrhythm 2017; 33:434-439. [PMID: 29021846 PMCID: PMC5634723 DOI: 10.1016/j.joa.2017.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/14/2017] [Accepted: 06/22/2017] [Indexed: 11/29/2022] Open
Abstract
Background The periprocedural protocol for atrial fibrillation (AF) ablation commonly includes anticoagulation therapy. Apixaban, a direct oral anticoagulant, is currently approved for clinical use; however, little is known about the effects of residual apixaban concentration on bleeding complications during/after AF ablation. Therefore, we measured residual apixaban concentration by using mass spectrometry and examined the anticoagulant's residual effects on bleeding complications. Methods Fifty-eight patients (Mean age of 64.7±12.5 years; 31 males, 27 females) were enrolled and administered apixaban twice daily. We analyzed trough apixaban concentration, activated clotting time (ACT), heparin dose, and bleeding complications during/after AF ablation. Apixaban concentrations were directly measured using mass spectrometry. Results Bleeding complications were observed in 19 patients (delayed hemostasis at the puncture site, 16; hematuria, 3; hemosputum, 1). No patient required blood transfusion. The mean trough apixaban concentration was significantly lower in patients with bleeding complications than without (152.4±73.1 vs. 206.8±98.8 ng/mL respectively, P=0.037), while the heparin dose to achieve ACT>300 s was significantly higher in patients with bleeding complications (9368.4±2929.0 vs. 7987.2±2135.2 U/body respectively, P=0.046). Interestingly, a negative correlation was found between the trough apixaban concentration and the heparin dose to achieve ACT>300 s (P=0.033, R=-0.281). Conclusions Low residual plasma apixaban is associated with a higher incidence of bleeding complications during/after AF ablation, potentially because of a greater heparin requirement during AF ablation.
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Affiliation(s)
- Yutaro Mukai
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.,Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Kyoichi Wada
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.,Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazuki Nakagita
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.,Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Mai Fujimoto
- Division of Clinical Drug Informatics, Kindai University School of Pharmacy, Higashi-osaka, Japan
| | - Kouichi Hosomi
- Division of Clinical Drug Informatics, Kindai University School of Pharmacy, Higashi-osaka, Japan
| | - Takeshi Kuwahara
- Department of Pharmacy, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsutaka Takada
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan.,Division of Clinical Drug Informatics, Kindai University School of Pharmacy, Higashi-osaka, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Akira Oita
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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20
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Shah RR, Pillai A, Schafer P, Meggo D, McElderry T, Plumb V, Yamada T, Kumar V, Doppalapudi H, Gunter A, Pentecost E, Maddox WR. Safety and Efficacy of Uninterrupted Apixaban Therapy Versus Warfarin During Atrial Fibrillation Ablation. Am J Cardiol 2017; 120:404-407. [PMID: 28595862 DOI: 10.1016/j.amjcard.2017.04.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/19/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022]
Abstract
Thromboembolic cerebrovascular accident remains a rare but potentially devastating complication of catheter-based atrial fibrillation (AF) ablation. Uninterrupted oral anticoagulant therapy with warfarin has become the standard of care when performing catheter-based AF ablation. Compared with warfarin, apixaban, a factor Xa inhibitor, has been shown to reduce the risk of stroke and major bleeding in nonvalvular AF. With an increase in apixaban use for stroke prophylaxis in patients with AF, there is an increased interest in the safety and efficacy of uninterrupted apixaban therapy during AF ablation. We compared the safety and efficacy of uninterrupted OA therapy with either warfarin or apixaban in all patients who underwent catheter-based AF ablation at the University of Alabama at Birmingham and at Augusta University Medical Center from January 7, 2013, to February 25, 2016. All patients underwent a transesophageal echocardiogram on the day of their ablation to assess for the presence of intracardiac thrombi. All complications were identified and classified as bleeding, thromboembolic events, or other. A total of 627 patients were analyzed as described earlier. There were 310 patients in the warfarin group and 317 patients in the apixaban group. There were 8 complications in the warfarin group and 5 complications in the apixaban group (p = 0.38). There were no thromboembolic complications in either group. In conclusion, the use of apixaban is as safe and effective as warfarin for uninterrupted OA therapy during catheter-based ablation of AF.
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21
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Dubois V, Dincq AS, Douxfils J, Ickx B, Samama CM, Dogné JM, Gourdin M, Chatelain B, Mullier F, Lessire S. Perioperative management of patients on direct oral anticoagulants. Thromb J 2017; 15:14. [PMID: 28515674 PMCID: PMC5433145 DOI: 10.1186/s12959-017-0137-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 05/04/2017] [Indexed: 12/31/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10-15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure. As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.
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Affiliation(s)
- Virginie Dubois
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Brigitte Ickx
- Université Libre de Bruxelles, Erasme University Hospital,Department of Anesthesiology, Brussels, Belgium
| | - Charles-Marc Samama
- Université Paris Descartes, Cochin University Hospital,Department of Anesthesiology and Intensive Care, Paris, France
| | - Jean-Michel Dogné
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Maximilien Gourdin
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Bernard Chatelain
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - Sarah Lessire
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
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Aagaard P, Briceno D, Csanadi Z, Mohanty S, Gianni C, Trivedi C, Nagy-Baló E, Danik S, Barrett C, Santoro F, Burkhardt JD, Sanchez J, Natale A, Di Biase L. Atrial Fibrillation Ablation and Stroke. Cardiol Clin 2017; 34:307-16. [PMID: 27150179 DOI: 10.1016/j.ccl.2015.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Catheter ablation has become a widely available and accepted treatment to restore sinus rhythm in atrial fibrillation patients who fail antiarrhythmic drug therapy. Although generally safe, the procedure carries a non-negligible risk of complications, including periprocedural cerebral insults. Uninterrupted anticoagulation, maintenance of an adequate ACT during the procedure, and measures to avoid and detect thrombus build-up on sheaths and atheters during the procedure, appears useful to reduce the risk of embolic events. This is a review of the incidence, mechanisms, impact, and methods to reduce catheter ablation related cerebral insults.
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Affiliation(s)
- Philip Aagaard
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Hospital, Bronx, NY, USA
| | - David Briceno
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Hospital, Bronx, NY, USA
| | - Zoltan Csanadi
- Department of Cardiology, University of Debrecen, 22 Móricz Zs, Debrecen H4032, Hungary
| | - Sanghamitra Mohanty
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Carola Gianni
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Chintan Trivedi
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Edina Nagy-Baló
- Department of Cardiology, University of Debrecen, 22 Móricz Zs, Debrecen H4032, Hungary
| | - Stephan Danik
- The Al-Sabah Arrhythmia Institute at Mount Sinai St. Luke, New York, NY, USA
| | - Conor Barrett
- The Al-Sabah Arrhythmia Institute at Mount Sinai St. Luke, New York, NY, USA
| | | | - J David Burkhardt
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Javier Sanchez
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Andrea Natale
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA; Division of Cardiology, Stanford University, Stanford, CA, USA; CaseWestern Reserve University, Cleveland, OH, USA; EP Services, California Pacific Medical Center, San Francisco, CA, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Dell Medical School, University of Texas, Austin, TX, USA.
| | - Luigi Di Biase
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA; Department of Cardiology, University of Foggia, Foggia, Italy; Department of Biomedical Engineering, University of Texas, Austin, TX, USA.
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23
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Briceno DF, Madan N, Villablanca PA, Lupercio F, Cyrille N, Ramakrishna H, Di Biase L. Periprocedural Anticoagulation for Catheter Ablation of Atrial Fibrillation: Practical Implications for Perioperative Management. J Cardiothorac Vasc Anesth 2017; 31:1519-1526. [PMID: 29335195 DOI: 10.1053/j.jvca.2016.09.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Indexed: 12/12/2022]
Affiliation(s)
- David F Briceno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Nidhi Madan
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Pedro A Villablanca
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Florentino Lupercio
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Nicole Cyrille
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic in Arizona, Phoenix, AZ.
| | - Luigi Di Biase
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY; Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX; Department of Biomedical Engineering, University of Texas at Austin, Austin, TX; Department of Cardiology, University of Foggia, Foggia, Italy
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24
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Impaired renal function is associated with recurrence after cryoballoon catheter ablation for paroxysmal atrial fibrillation: A potential effect of non-pulmonary vein foci. J Cardiol 2017; 69:3-10. [DOI: 10.1016/j.jjcc.2016.07.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 07/02/2016] [Accepted: 07/13/2016] [Indexed: 11/18/2022]
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25
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Okishige K, Nakamura T, Aoyagi H, Kawaguchi N, Yamashita M, Kurabayashi M, Suzuki H, Asano M, Shimura T, Yamauchi Y, Sasano T, Hirao K. Comparative study of hemorrhagic and ischemic complications among anticoagulants in patients undergoing cryoballoon ablation for atrial fibrillation. J Cardiol 2017; 69:11-15. [DOI: 10.1016/j.jjcc.2016.04.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 03/31/2016] [Accepted: 04/09/2016] [Indexed: 11/15/2022]
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26
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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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27
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Iwasaki YK, Shimizu W. Current Optimal Anticoagulation Regimen of Rivaroxaban in Atrial Fibrillation Catheter Ablation. Circ J 2016; 80:2287-2288. [PMID: 27725528 DOI: 10.1253/circj.cj-16-0992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yu-Ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
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28
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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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29
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Yanagisawa S, Inden Y, Kato H, Fujii A, Mizutani Y, Ito T, Kamikubo Y, Kanzaki Y, Ando M, Hirai M, Shibata R, Murohara T. Effect and Significance of Early Reablation for the Treatment of Early Recurrence of Atrial Fibrillation After Catheter Ablation. Am J Cardiol 2016; 118:833-841. [PMID: 27453516 DOI: 10.1016/j.amjcard.2016.06.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/15/2016] [Accepted: 06/15/2016] [Indexed: 01/07/2023]
Abstract
There are few reports on early reablation (ER) for early recurrence of atrial fibrillation (AF) after catheter ablation. The present study evaluated the efficacy and significance of ER for early recurrence within a blanking period of 3 months after ablation of both paroxysmal and persistent AF, using a propensity-matched analysis. Of 874 patients who underwent catheter ablation of AF, 389 (45%) had early recurrence. Of these, 78 patients underwent an ER procedure. A total of 132 matched patients (66 in the ER and 66 in the non-ER groups, 82 patients with paroxysmal AF) were included in the analysis. During a mean follow-up of 15.4 months, the patients who underwent ER had a significantly lower recurrence rate than those who did not (29 [44%] vs 42 patients [64%], p = 0.023). The benefit of ER was especially apparent in patients with paroxysmal AF (p = 0.008) but not in those with persistent AF (p = 0.774). However, 24 patients (36%) in the non-ER group did not experience recurrence after a blanking period without any reablation procedure. The total number of reablation sessions was higher in the ER group than in the non-ER group (1.2 ± 0.5 vs 0.4 ± 0.6, p <0.001). Nonetheless, mean number of arrhythmia outpatient clinic visits at follow-up was significantly fewer in the ER group than in the late reablation group. In conclusion, ER for early recurrence of AF after catheter ablation might be effective for preventing recurrence during follow-up, especially for paroxysmal AF.
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30
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Dilaveris P, Tousoulis D. Periprocedural anticoagulation in patients undergoing cryoballoon ablation for atrial fibrillation. Hellenic J Cardiol 2016; 57:338-339. [DOI: 10.1016/j.hjc.2017.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 11/21/2016] [Indexed: 11/24/2022] Open
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31
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Sankaranarayanan R, Fox DJ. Are Some Anticoagulants More Equal Than Others? - Evaluating the Role of Novel Oral Anticoagulants in AF Ablation. Curr Cardiol Rev 2016; 12:330-335. [PMID: 27146837 PMCID: PMC5304256 DOI: 10.2174/1573403x12666160505113755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 04/22/2016] [Accepted: 04/26/2016] [Indexed: 12/02/2022] Open
Abstract
Left atrial ablation strategies are being increasingly performed as a Class 1 therapeutic indication for drug refractory paroxysmal atrial fibrillation (AF). Traditionally AF ablation has been performed with patients on uninterrupted warfarin therapy, however over the last few years, novel oral anticoagulants (NOACs) have emerged as attractive alternatives to warfarin in order to reduce stroke risk due to AF. NOACs are therefore increasingly being used instead of warfarin in the management of AF. There is also mounting evidence mainly in the form of small randomised studies and meta-analysis that have demonstrated that the use of NOACs for AF ablation is efficacious, safe and convenient. However the peri-procedural dosing protocols used in various studies especially in terms of whether NOAC use is interrupted or uninterrupted during AF ablation, have significant inter-operator and inter-institution variability. Currently there is also a lack of randomised controlled trials to validate the data obtained from meta-analyses. There is also evidence that use of NOACs may increase the requirement of unfractionated heparin during the procedure. This review article shall examine the currently available evidence-base, appraise the gaps in the current evidence and also underscore the need for larger randomised clinical trials in this rapidly developing field.
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Affiliation(s)
- Rajiv Sankaranarayanan
- University of Manchester and Northwest Heart Centre, University Hospital of South Manchester, Manchester, UK.
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32
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He Y, Wong ICK, Li X, Anand S, Leung WK, Siu CW, Chan EW. The association between non-vitamin K antagonist oral anticoagulants and gastrointestinal bleeding: a meta-analysis of observational studies. Br J Clin Pharmacol 2016; 82:285-300. [PMID: 26889922 DOI: 10.1111/bcp.12911] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/12/2016] [Accepted: 02/14/2016] [Indexed: 12/21/2022] Open
Abstract
Particular concerns have been raised regarding the association between non-vitamin K antagonist oral anticoagulants (NOACs) and the risk of gastrointestinal bleeding (GIB); however, current findings are still inconclusive. We conducted a systematic review with a meta-analysis to examine the association between NOACs and GIB in real-life settings. We performed a systematic search of PubMed, EMBASE and CINAHL Plus up to September 2015. Observational studies that evaluated exposure to NOACs reporting GIB outcomes were included. The inverse variance method using the random-effects model was used to calculate the pooled estimates. Eight cohort studies were included in the primary meta-analysis, enrolling 1442 GIB cases among 106 626 dabigatran users (49 486 patient-years), and 184 GIB cases among 10 713 rivaroxaban users (4046 patient-years). The pooled incidence rates of GIB were 4.50 [95% confidence interval (CI) 3.17, 5.84] and 7.18 (95% CI 2.42, 12.0) per 100 patient-years among dabigatran and rivaroxaban users, respectively. The summary risk ratio (RR) was 1.21 (95% CI 1.05, 1.39) for dabigatran compared with warfarin, and 1.09 (95% CI 0.92, 1.30) for rivaroxaban. Subgroup analyses showed a dose-related effect of dabigatran, with a significantly higher risk of GIB for 150 mg b.i.d. (RR = 1.51, 95% CI 1.34, 1.70) but not for 75 mg b.i.d. or 110 mg b.i.d.. In addition, the use of proton pump inhibitors (PPIs)/histamine H2-receptor antagonists (H2RAs) influenced the association in dabigatran users, whereas this effect was modest among rivaroxaban users. In conclusion, our meta-analysis suggested a slightly higher risk of GIB with dabigatran use compared with warfarin, whereas no significant difference was found between rivaroxaban and warfarin for GIB risk.
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Affiliation(s)
- Ying He
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong.,Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Xue Li
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
| | - Shweta Anand
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
| | - Wai K Leung
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Chung Wah Siu
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Esther W Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
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33
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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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34
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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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35
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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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Kuwahara T, Abe M, Yamaki M, Fujieda H, Abe Y, Hashimoto K, Ishiba M, Sakai H, Hishikari K, Takigawa M, Okubo K, Takagi K, Tanaka Y, Nakajima J, Takahashi A. Apixaban versus Warfarin for the Prevention of Periprocedural Cerebral Thromboembolism in Atrial Fibrillation Ablation: Multicenter Prospective Randomized Study. J Cardiovasc Electrophysiol 2016; 27:549-54. [PMID: 26766541 DOI: 10.1111/jce.12928] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/01/2016] [Accepted: 01/08/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Stroke can be a life-threatening complication of atrial fibrillation (AF) catheter ablation. Uninterrupted warfarin treatment contributes to minimizing the risk of stroke complications. METHODS AND RESULTS This was a prospective, open-label, randomized, multicenter study assessing the safety and efficacy of apixaban for the prevention of cerebral thromboembolism complicating AF catheter ablation. Two hundred patients with drug-resistant AF were equally assigned to take either apixaban (5 mg or 2.5 mg twice daily) or warfarin (target international normalized ratio, 2-3) for at least 1 month before AF ablation. Neither drug regimen was interrupted throughout the operative period. Diffusion-weighted magnetic resonance imaging was performed for all patients to detect silent cerebral infarction (SCI) after the ablation. Primary outcomes were defined as the occurrence of stroke, transient ischemic attack, SCI, or major bleeding that required intervention. The secondary outcome was minor bleeding. The groups did not statistically differ in patients' backgrounds or procedural parameters. During AF ablation, the apixaban group required administration of more heparin to maintain an activated clotting time > 300 seconds than the warfarin group (apixaban, 14,000 ± 4,000 units; warfarin, 9,000 ± 3,000 units). Three primary outcome events occurred in each group (apixaban, 2 SCI and 1 major bleed; warfarin, 3 SCI, P = 1.00), and 3 and 4 secondary outcome events occurred in the apixaban and warfarin groups (P = 0.70), respectively. CONCLUSION Apixaban has similar safety and effectiveness to warfarin for the prevention of cerebral thromboembolism during the periprocedural period of AF ablation.
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Affiliation(s)
- Taishi Kuwahara
- Cardiovascular Center, Yokosuka Kyousai Hospital, Yokosuka, Kanagawa, Japan
| | | | - Masaru Yamaki
- Cardiovascular Division, Nayoro General Hospital, Nayoro, Hokkaido, Japan
| | | | - Yumiko Abe
- Yotsuba Circulation Clinic, Matsuyama, Ehime, Japan
| | | | - Misako Ishiba
- Cardiovascular Division, Nayoro General Hospital, Nayoro, Hokkaido, Japan
| | - Hirotsuka Sakai
- Cardiovascular Division, Nayoro General Hospital, Nayoro, Hokkaido, Japan
| | - Keiichi Hishikari
- Cardiovascular Center, Yokosuka Kyousai Hospital, Yokosuka, Kanagawa, Japan
| | - Masateru Takigawa
- Cardiovascular Center, Yokosuka Kyousai Hospital, Yokosuka, Kanagawa, Japan
| | - Kenji Okubo
- Cardiovascular Center, Yokosuka Kyousai Hospital, Yokosuka, Kanagawa, Japan
| | - Katsumasa Takagi
- Cardiovascular Center, Yokosuka Kyousai Hospital, Yokosuka, Kanagawa, Japan
| | - Yasuaki Tanaka
- Cardiovascular Center, Yokosuka Kyousai Hospital, Yokosuka, Kanagawa, Japan
| | - Jun Nakajima
- Cardiovascular Center, Yokosuka Kyousai Hospital, Yokosuka, Kanagawa, Japan
| | - Atsushi Takahashi
- Cardiovascular Center, Yokosuka Kyousai Hospital, Yokosuka, Kanagawa, Japan
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Forleo GB, Della Rocca DG, Lavalle C, Mantica M, Papavasileiou LP, Ribatti V, Panattoni G, Santini L, Natale A, Biase LD. A Patient With Asymptomatic Cerebral Lesions During AF Ablation: How Much Should We Worry? J Atr Fibrillation 2016; 8:1323. [PMID: 27909472 PMCID: PMC5089485 DOI: 10.4022/jafib.1323] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 01/09/2023]
Abstract
Silent brain lesions due to thrombogenicity of the procedure represent recognized side effects of atrial fibrillation (AF) catheter ablation. Embolic risk is higher if anticoagulation is inadequate and recent studies suggest that uninterrupted anticoagulation, ACT levels above 300 seconds and administration of a pre-transeptal bolus of heparin might significantly reduce the incidence of silent cerebral ischemia (SCI) to 2%. Asymptomatic new lesions during AF ablation should suggest worse neuropsychological outcome as a result of the association between silent cerebral infarcts and increased long-term risk of dementia in non-ablated AF patients. However, the available data are discordant. To date, no study has definitely linked post-operative asymptomatic cerebral events to a decline in neuropsychological performance. Larger volumes of cerebral lesions have been associated with cognitive decline but are uncommon findings acutely in post-ablation AF patients. Of note, the majority of acute lesions have a small or medium size and often regress at a medium-term follow-up. Successful AF ablation has the potential to reduce the risk of larger SCI that may be considered as part of the natural course of AF. Although the long-term implications of SCI remain unclear, it is conceivable that strategies to reduce the risk of SCI may be beneficial.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Andrea Natale
- Policlinico Tor Vergata, Rome, Italy; Policlinico Tor Vergata, Rome, Italy
| | - Luigi Di Biase
- Policlinico Tor Vergata, Rome, Italy; Policlinico Tor Vergata, Rome, Italy
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Periprocedural management of anticoagulation in patients taking novel oral anticoagulants: Review of the literature and recommendations for specific populations and procedures. Int J Cardiol 2016; 202:578-85. [DOI: 10.1016/j.ijcard.2015.09.035] [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] [Received: 07/20/2015] [Revised: 08/30/2015] [Accepted: 09/19/2015] [Indexed: 12/17/2022]
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YANAGISAWA SATOSHI, INDEN YASUYA, KATO HIROYUKI, FUJII AYA, MIZUTANI YOSHIAKI, ITO TADAHIRO, KAMIKUBO YOSUKE, KANZAKI YASUNORI, HIRAI MAKOTO, MUROHARA TOYOAKI. Decrease in B-Type Natriuretic Peptide Levels and Successful Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 39:225-34. [DOI: 10.1111/pace.12788] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/11/2015] [Accepted: 11/15/2015] [Indexed: 11/27/2022]
Affiliation(s)
- SATOSHI YANAGISAWA
- Department of Cardiology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - YASUYA INDEN
- Department of Cardiology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - HIROYUKI KATO
- Department of Cardiology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - AYA FUJII
- Department of Cardiology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - YOSHIAKI MIZUTANI
- Department of Cardiology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - TADAHIRO ITO
- Department of Cardiology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - YOSUKE KAMIKUBO
- Department of Cardiology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - YASUNORI KANZAKI
- Department of Cardiology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - MAKOTO HIRAI
- Department of Cardiology; Nagoya University Graduate School of Health Science; Nagoya Japan
| | - TOYOAKI MUROHARA
- Department of Cardiology; Nagoya University Graduate School of Medicine; Nagoya Japan
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40
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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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Rillig A, Lin T, Plesman J, Heeger CH, Lemes C, Metzner A, Mathew S, Wissner E, Wohlmuth P, Ouyang F, Kuck KH, Tilz RR. Apixaban, Rivaroxaban, and Dabigatran in Patients Undergoing Atrial Fibrillation Ablation. J Cardiovasc Electrophysiol 2015; 27:147-53. [PMID: 26464027 DOI: 10.1111/jce.12856] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 09/19/2015] [Accepted: 10/05/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Data on the novel oral anticoagulants (NOACS) during catheter ablation (CA) of atrial fibrillation (AF) are still limited. This study evaluated the periprocedural major complications (MC) of CA of AF, and compared Apixaban, Dabigatran, and Rivaroxaban with continuous phenoprocoumon. METHODS AND RESULTS A total of 444 patients (mean age = 65.1 ± 9.4 years; 283 [64%] male) with paroxysmal (n = 180 [41%]), persistent (n = 256 [58%]), or longstanding-persistent AF were enrolled. CA was performed in all patients using radiofrequency energy in conjunction with a 3D-mapping system. MCs were defined according to the current guidelines. Continuous phenprocoumon-therapy was administered in 120/444 (27%) patients (group 1) and 324/444 (73%) patients were treated with NOACs (group 2; Dabigatran: n = 51 [15.7%]; Rivaroxaban: n = 193 [59.6%]; Apixaban: n = 80 [24.7%]). Procedure times were comparable between groups 1 and 2 (128.2 ± 39.7 minutes vs. 129.7 ± 51.2 minutes; P = 0.77). CHA2 DS2-Vasc (3.0 [2.0, 4.0)] vs. 2.0 [1.0, 3.0]; P < 0.01) and HASBLED scores (2.0 [2.0, 2.5] vs. 2.0 [1.0, 2.0]; P = 0.002) were higher in group 1 patients. The incidence of MCs in the overall group was 8/444 (2%) and was equally distributed between groups 1 and 2 (2/120 [2%] vs. 6/324 [2%], P = 0.90). The incidence of MCs was comparable between the three different NOACs. There were no significant differences between patients with and without MCs with regard to age, CHA2 DS2-Vasc-score or HASBLED-score. CONCLUSIONS The major complication rate between all three NOACs currently available and continuous phenprocoumon during AF ablation seem to be comparable. Complication rates were similar between patients treated with the three different available NOACs.
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Affiliation(s)
- Andreas Rillig
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Tina Lin
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Joaquina Plesman
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | - Christine Lemes
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Shibu Mathew
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Erik Wissner
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | - Feifan Ouyang
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Karl-Heinz Kuck
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
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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: 793] [Impact Index Per Article: 88.1] [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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45
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Feasibility and safety of uninterrupted periprocedural apixaban administration in patients undergoing radiofrequency catheter ablation for atrial fibrillation: Results from a multicenter study. Heart Rhythm 2015; 12:1162-8. [DOI: 10.1016/j.hrthm.2015.02.028] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Indexed: 11/21/2022]
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Rajagopalan B, Curtis AB. Management of atrial fibrillation: What is new in the 2014 ACC/AHA/HRS guideline? Postgrad Med 2015; 127:396-404. [PMID: 25746135 DOI: 10.1080/00325481.2015.1022495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Recently, the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society published an updated guideline on the management of atrial fibrillation (AF). This document is a complete revision of the 2006 guideline. Prominent changes in the 2014 guideline include the use of the CHA2DS2-VASc score for risk stratification of stroke, recommendations on when and how to use newer oral anticoagulants for thromboprophylaxis, downgrading of the use of aspirin for thromboprophylaxis of moderate-risk patients, and the use of catheter ablation in selected patients as first-line therapy for paroxysmal AF. In regard to rate control, the 2014 guideline reverts back to a previous recommendation for stricter targets for mean and maximum heart rate on therapy. The current guideline incorporates many recent trials in updating existing recommendations from the 2006 guideline. The 2014 guideline will be a vital tool in guiding physicians in the management of AF.
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