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Ding WY, Calvert P, Lip GYH, Gupta D. Novel stroke prevention strategies following catheter ablation for atrial fibrillation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:690-696. [PMID: 38428582 DOI: 10.1016/j.rec.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/14/2024] [Indexed: 03/03/2024]
Abstract
Stroke prevention following successful catheter ablation of atrial fibrillation remains a controversial topic. Oral anticoagulation is associated with a significant reduction in stroke risk in the general atrial fibrillation population but may be associated with an increased risk of major bleeding, and the benefit: risk ratio must be considered. Improvement in successful catheter ablation and widespread use of cardiac monitoring devices may allow for novel anticoagulation strategies in a subset of patients with atrial fibrillation, which may optimize stroke prevention while minimizing bleeding risk. In this review, we discuss stroke risk in atrial fibrillation and the effects of successful catheter ablation on thromboembolic risk. We also explore novel strategies for stroke prevention following successful catheter ablation.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Centre for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Kanaoka K, Nishida T, Iwanaga Y, Nakai M, Tonegawa-Kuji R, Nishioka Y, Myojin T, Okada K, Noda T, Kusano K, Miyamoto Y, Saito Y, Imamura T. Oral anticoagulation after atrial fibrillation catheter ablation: benefits and risks. Eur Heart J 2024; 45:522-534. [PMID: 38117227 PMCID: PMC10873714 DOI: 10.1093/eurheartj/ehad798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/20/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND AND AIMS Few recent large-scale studies have evaluated the risks and benefits of continuing oral anticoagulant (OAC) therapy after catheter ablation (CA) for atrial fibrillation (AF). This study evaluated the status of continuation of OAC therapy and the association between continuation of OAC therapy and thromboembolic and bleeding events according to the CHADS2 score. METHODS This retrospective study included data from the Japanese nationwide administrative claims database of patients who underwent CA for AF between April 2014 and March 2021. Patients without AF recurrence assessed by administrative data of the treatment modalities were divided into two groups according to continuation of OAC therapy 6 months after the index CA. The primary outcomes were thromboembolism and major bleeding after a landmark period of 6 months. After inverse probability of treatment weighting analysis, the association between OAC continuation and outcomes was determined according to the CHADS2 score. RESULTS Among 231 374 patients included, 69.7%, 21.6%, and 8.7% had CHADS2 scores of ≤1, 2, and ≥3, respectively. Of these, 71% continued OAC therapy at 6 months. The OAC continuation rate was higher in the high CHADS2 score group than that in the low CHADS2 score group. Among all patients, 2451 patients (0.55 per 100 person-years) had thromboembolism and 2367 (0.53 per 100 person-years) had major bleeding. In the CHADS2 score ≤1 group, the hazard ratio of the continued OAC group was 0.86 [95% confidence interval (CI): 0.74-1.01, P = .06] for thromboembolism and was 1.51 (95% CI: 1.27-1.80, P < .001) for major bleeding. In the CHADS2 score ≥3 group, the hazard ratio of the continued OAC group was 0.61 (95% CI: 0.46-0.82, P = .001) for thromboembolism and was 1.05 (95% CI: 0.71-1.56, P = 0.81) for major bleeding. CONCLUSIONS This observational study suggests that the benefits and risks of continuing OAC therapy after CA for AF differ based on the patient's CHADS2 score. The risk of major bleeding due to OAC continuation seems to outweigh the risk reduction of thromboembolism in patients with lower thromboembolic risk.
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Affiliation(s)
- Koshiro Kanaoka
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Kishibe-Shimmachi 6-1, Suita, Osaka 564-8565, Japan
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Taku Nishida
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Kishibe-Shimmachi 6-1, Suita, Osaka 564-8565, Japan
- Department of Cardiology, Sakurabashi-Watanabe Hospital, Umeda 2-4-32, Osaka, Osaka 530-0001, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Kishibe-Shimmachi 6-1, Suita, Osaka 564-8565, Japan
| | - Reina Tonegawa-Kuji
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Kishibe-Shimmachi 6-1, Suita, Osaka 564-8565, Japan
| | - Yuichi Nishioka
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
| | - Tomoya Myojin
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Medical Informatics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tatsuya Noda
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihiro Miyamoto
- Open Innovation Center, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Nara, Japan
- Nara Prefecture Seiwa Medical Center, Sango, Nara, Japan
| | - Tomoaki Imamura
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
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Wang X, Li M, Wang X, Zhang Z. It can be safe to discontinue oral anticoagulants after successful atrial fibrillation ablation: A systematic review and meta-analysis of cohort studies. Medicine (Baltimore) 2023; 102:e35518. [PMID: 37861532 PMCID: PMC10589570 DOI: 10.1097/md.0000000000035518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/14/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Current guidelines recommended that oral anticoagulants (OACs) should last for a minimum first 2 months after atrial fibrillation (AF) ablation and the long-term decision of anticoagulation after AF ablation should be based on the individual patient's risk of stroke rather than the rhythm status. There is controversy about the safety of discontinuing OACs in patients with atrial fibrillation after the blanking period due to the divergences between consensus recommendations and clinical practice. METHODS Electronic bibliographic sources (PubMed, Embase, and Web of Science) were searched until August 2023 to identify cohort studies about the safety of discontinuing OACs in patients with AF after the blanking period. The primary outcome was thromboembolism (TE). The secondary outcome was major bleeding events (MBEs). Two authors extracted articles independently using predefined data fields. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated based on a random-effects model. RESULTS A total of 16 studies (11 prospective cohorts and 5 retrospective cohorts) enrolling 23,942 patients (14,382 OFF-OAC and 9560 ON-OAC) were included in our analysis. No significant difference emerged in the risk of TE between OFF-OAC and ON-OAC patients following AF ablation after the banking period (OR = 0.66; 95%CI, 0.43-1.01). Similar results emerged in the patients with a high risk of TE after stratification by the risk level of TE (OR = 0.72; 95%CI, 0.25-2.08). A significant reduction in incidences of major bleeding was found in the OFF-OAC patients compared with the ON-OAC patients (OR = 0.23; 95%CI, 0.12-0.42). Subgroup analyses for TE found a reduction of incidences in the subgroups who switched to antiplatelet drugs and with a follow-up duration <3 years. Subgroup analyses for MBEs found a significant reduction of incidences in all subgroups. CONCLUSIONS Our study suggests it can be safe to discontinue OACs after successful AF ablation. Discontinuation of OACs may reduce the risk of MBEs while not increasing the risk of TE.
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Affiliation(s)
- Xiangyu Wang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Minghua Li
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Xishu Wang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Zhiguo Zhang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin Province, China
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Tsuda T, Kato T, Usuda K, Kusayama T, Usui S, Sakata K, Hayashi K, Kawashiri MA, Yamagishi M, Takamura M, Otsuka T, Suzuki S, Hirata A, Murakami M, Takami M, Kimura M, Fukaya H, Nakahara S, Shimizu W, Iwasaki YK, Hayashi H, Harada T, Nakajima I, Okumura K, Koyama J, Tokuda M, Yamane T, Momiyama Y, Tanimoto K, Soejima K, Nonoguchi N, Ejima K, Hagiwara N, Harada M, Sonoda K, Inoue M, Kumagai K, Hayashi H, Satomi K, Yazaki Y, Watari Y, Arai M, Watanabe R, Yokoyama K, Matsumoto N, Nagashima K, Okumura Y. Effect of Catheter Ablation for Atrial Fibrillation in Heart Failure With Mid-Range or Preserved Ejection Fraction - Pooled Analysis of the AF Frontier Ablation Registry and Hokuriku-Plus AF Registry. Circ J 2023; 87:939-946. [PMID: 36464278 DOI: 10.1253/circj.cj-22-0461] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2024]
Abstract
BACKGROUND A recent randomized trial demonstrated that catheter ablation for atrial fibrillation (AF) in patients with heart failure with reduced ejection fraction (EF) is associated with a reduction in death or heart failure. However, the effect of catheter ablation for AF in patients with heart failure with mid-range or preserved EF is unclear. METHODS AND RESULTS We screened 899 AF patients (72.4% male, mean age 68.4 years) with heart failure and left ventricular EF ≥40% from 2 Japanese multicenter AF registries: the Atrial Fibrillation registry to Follow the long-teRm Outcomes and use of aNTIcoagulants aftER Ablation (AF Frontier Ablation Registry) as the ablation group (525 patients who underwent ablation) and the Hokuriku-Plus AF Registry as the medical therapy group (374 patients who did not undergo ablation). Propensity score matching was performed in these 2 registries to yield 106 matched patient pairs. The primary endpoint was a composite of cardiovascular death and hospitalization for heart failure. At 24.6 months, the ablation group had a significantly lower incidence of the primary endpoint (hazard ratio 0.32; 95% confidence interval 0.13-0.70; P=0.004) than the medical therapy group. CONCLUSIONS Compared with medical therapy, catheter ablation for AF in patients with heart failure and mid-range or preserved EF was associated with a significantly lower incidence of cardiovascular death or hospitalization for heart failure.
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Affiliation(s)
- Toyonobu Tsuda
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Takeshi Kato
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | | | - Takashi Kusayama
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Soichiro Usui
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Kenji Sakata
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | | | | | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | | | - Shinya Suzuki
- Department of Cardiology, The Cardiovascular Institute
| | - Akio Hirata
- Cardiovascular Division, Osaka Police Hospital
| | | | | | - Masaomi Kimura
- Division of Cardiology, Pulmonary Medicine and Nephrology, Hirosaki University School of Medicine
| | | | | | | | | | | | - Tomoo Harada
- St. Marianna University School of Medicine Hospital
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Masaru Arai
- Division of Cardiology, Nihon University Itabashi Hospital
| | - Ryuta Watanabe
- Division of Cardiology, Nihon University Itabashi Hospital
| | | | | | | | - Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital
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Hirata M, Nagashima K, Watanabe R, Wakamatsu Y, Otsuka N, Hayashida S, Hirata S, Sawada M, Kurokawa S, Okumura Y. Trends over the recent 6 years in ablation modalities and strategies, post-ablation medication, and clinical outcomes of atrial fibrillation ablation. J Arrhythm 2023; 39:366-375. [PMID: 37324765 PMCID: PMC10264728 DOI: 10.1002/joa3.12854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/28/2023] [Accepted: 04/04/2023] [Indexed: 06/17/2023] Open
Abstract
Background Ablation strategies and modalities for atrial fibrillation (AF) have transitioned over the past decade, but their impact on post-ablation medication and clinical outcomes remains to be fully investigated. Methods We divided 682 patients who had undergone AF ablation in 2014-2019 (420 paroxysmal AFs [PAF], 262 persistent AFs [PerAF]) into three groups according to the period, that is, the 2014-2015 (n = 139), 2016-2017 (n = 244), and 2018-2019 groups (n = 299), respectively. Results Persistent AF became more prevalent and the left atrial (LA) diameter larger over the 6 years. Extra-pulmonary vein (PV)-LA ablation was more frequently performed in the 2014-2015 group than in the 2016-2017 and 2018-2019 groups (41.1% vs. 9.1% and 8.1%; p < .001). The 2-year freedom rate from AF/atrial tachycardias for PAF was similar among the three groups (84.0% vs. 83.1% vs. 86.7%; p = .98) but lowest in the 2014-2015 group for PerAF (63.9% vs. 82.7% and 86.3%; p = .025) despite the highest post-ablation antiarrhythmic drug use. Cardiac tamponade was significantly decreased in the 2018-2019 group (3.6% vs. 2.0% vs. 0.33%; p = 0.021). There was no difference in the 2-year clinically relevant events among the three groups. Conclusion Although ablation was performed in a more diseased LA and extra-PV-LA ablation was less frequent in recent years, the complication rate decreased, and AF recurrences for PAF remained unchanged, but that for PerAF decreased. Clinically relevant events remained unchanged over the recent 6 years, suggesting that the impact of the recent ablation modalities and strategies on remote clinically relevant events may be small during this study period.
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Affiliation(s)
- Moyuru Hirata
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Koichi Nagashima
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Ryuta Watanabe
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Naoto Otsuka
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Satoshi Hayashida
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Shu Hirata
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Masanaru Sawada
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
| | - Yasuo Okumura
- Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
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Watanabe R, Okumura Y. What Are the Optimal Anticoagulation Strategies Before, During, and After Catheter Ablation of Atrial Fibrillation? Circ J 2022; 87:63-64. [PMID: 36171084 DOI: 10.1253/circj.cj-22-0516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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Nogami A, Soejima K, Morishima I, Hiroshima K, Kato R, Sakagami S, Miura F, Okawa K, Kimura T, Inoue T, Takita A, Uno K, Kumagai K, Kurita T, Gosho M, Aonuma K. Real-World Investigation on Anticoagulation Management Before and After Catheter Ablation for Atrial Fibrillation in Japan - Periprocedural and Long-Term Outcomes. Circ J 2022; 87:50-62. [PMID: 35989303 DOI: 10.1253/circj.cj-22-0290] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Optimal periprocedural oral anticoagulant (OAC) therapy before catheter ablation (CA) for atrial fibrillation (AF) and the safety profile of OAC discontinuation during the remote period (from 31 days and up to 1 year after CA) have not been well defined. METHODS AND RESULTS The RYOUMA registry is a prospective multicenter observational study of Japanese patients who underwent CA for AF in 2017-2018. Of the 3,072 patients, 82.3% received minimally interrupted direct-acting OACs (DOACs) and 10.2% received uninterrupted DOACs. Both uninterrupted and minimally interrupted DOACs were associated with an extremely low thromboembolic event rate. Female, long-standing persistent AF, low creatinine clearance, hepatic disorder, and high intraprocedural heparin dose were independent factors associated with periprocedural major bleeding. At 1 year after CA, DOAC was continued in 55.9% of patients and warfarin in 56.4%. The incidence of thromboembolic and major bleeding events for 1 year was 0.3% and 1.2%, respectively. Age ≥73 years, dementia, and AF recurrence were independently associated with major bleeding events. Univariate analyses revealed that warfarin continuation and off-label overdose of DOACs were risk factors for major bleeding after CA. CONCLUSIONS High intraprocedural dose of heparin was associated with periprocedural major bleeding events. At 1 year after CA, over half of the patients had continued OAC therapy. Thromboembolic events were extremely low; however, major bleeding occurred in 1.2%. Age ≥73 years, dementia, and AF recurrence were independently associated with major bleeding after CA.
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Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Department of Cardiology, Kyorin University School of Medicine
| | | | | | - Ritsushi Kato
- Department of Arrhythmia, Saitama Medical University International Medical Center
| | - Satoru Sakagami
- Department of Cardiology, National Hospital Organization Kanazawa Medical Center
| | - Fumiharu Miura
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital
| | - Keisuke Okawa
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital
| | - Tetsuya Kimura
- Primary Medical Science Department, DAIICHI SANKYO Co., Ltd
| | - Takashi Inoue
- Primary Medical Science Department, DAIICHI SANKYO Co., Ltd
| | | | - Kikuya Uno
- Heart Rhythm Center, Tokyo Heart Rhythm Hospital
| | | | - Takashi Kurita
- Division of Cardiovascular Center, Kindai University School of Medicine
| | - Masahiko Gosho
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba
| | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
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Watanabe R, Nagashima K, Wakamatsu Y, Otsuka N, Yokoyama K, Matsumoto N, Otsuka T, Suzuki S, Hirata A, Murakami M, Takami M, Kimura M, Fukaya H, Nakahara S, Kato T, Hayashi H, Iwasaki YK, Shimizu W, Nakajima I, Harada T, Koyama J, Okumura K, Tokuda M, Yamane T, Tanimoto K, Momiyama Y, Nonoguchi N, Soejima K, Ejima K, Hagiwara N, Harada M, Sonoda K, Inoue M, Kumagai K, Hayashi H, Yazaki Y, Satomi K, Watari Y, Okumura Y. Different Determinants of the Recurrence of Atrial Fibrillation and Adverse Clinical Events in the Mid-Term Period After Atrial Fibrillation Ablation. Circ J 2022; 86:233-242. [PMID: 34219078 DOI: 10.1253/circj.cj-21-0326] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND It is unclear whether there are differences in the clinical factors between atrial fibrillation (AF) recurrence and adverse clinical events (AEs), including stroke/transient ischemic attack (TIA), major bleeding, and death, after AF ablation. METHODS AND RESULTS We examined the data from a retrospective multicenter Japanese registry conducted at 24 cardiovascular centers between 2011 and 2017. Of the 3,451 patients (74.1% men; 63.3±10.3 years) who underwent AF ablation, 1,046 (30.3%) had AF recurrence and 224 (6.5%) suffered AEs (51 strokes/TIAs, 71 major bleeding events, and 36 deaths) over a median follow-up of 20.7 months. After multivariate adjustment, female sex, persistent and long-lasting persistent AF (vs. paroxysmal AF), and stepwise increased left atrial diameter (LAd) quartiles were significantly associated with post-ablation recurrences. A multivariate analysis revealed that an age ≥75 years (vs. <65 years), body weight <50 kg, diabetes, vascular disease, left ventricular (LV) ejection fraction <40% (vs. ≥50%), Lad ≥44 mm (vs. <36 mm), and creatinine clearance <50 mL/min were independently associated with AE incidences, but not with recurrences. CONCLUSIONS This study disclosed different determinants of post-ablation recurrence and AEs. Female sex, persistent AF, and enlarged LAd were determinants of post-ablation recurrence, whereas an old age, comorbidities, and LV and renal dysfunction rather than post-ablation recurrence were AEs determinants. These findings will help determine ablation indications and post-ablation management.
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Affiliation(s)
- Ryuta Watanabe
- Division of Cardiology, Nihon University Itabashi Hospital
- Department of Cardiology, Nihon University Hospital
| | | | - Yuji Wakamatsu
- Division of Cardiology, Nihon University Itabashi Hospital
| | - Naoto Otsuka
- Division of Cardiology, Nihon University Itabashi Hospital
| | | | | | | | - Shinya Suzuki
- Department of Cardiology, The Cardiovascular Institute
| | - Akio Hirata
- Cardiovascular Division, Osaka Police Hospital
| | | | | | | | - Hidehira Fukaya
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | | | | | | | | | | | - Tomoo Harada
- St. Marianna University School of Medicine Hospital
| | | | | | | | - Teiichi Yamane
- Division of Cardiology, The Jikei University School of Medicine
| | | | | | | | | | | | | | | | | | | | | | - Hidemori Hayashi
- Department of Cardiology, Juntendo University School of Medicine
| | | | | | - Yuji Watari
- Department of Cardiology, Teikyo University School of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital
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Zhang Z, Jiang C, He L, Bai Y, Wu J, Hu R, Lv Q, Ning M, Feng L, Tang R, Sang C, Long D, Dong J, Du X, Lip GYH, Ma C. Associations of anemia with death and major bleeding in patients with atrial fibrillation: A report from the Chinese Atrial Fibrillation Registry Study. Clin Cardiol 2021; 45:91-100. [PMID: 34964140 PMCID: PMC8799039 DOI: 10.1002/clc.23764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/12/2021] [Accepted: 12/13/2021] [Indexed: 01/26/2023] Open
Abstract
Background Anemia is a common comorbidity in patients with atrial fibrillation (AF). Reports on the association of anemia and adverse events in patients with AF, especially from Asia, are limited. Methods and Results Based on data from the Chinese Atrial Fibrillation Registry Study (CAFR), a total of 18,106 AF patients enrolled between August 2011 and December 2018 had hemoglobin (Hb) values recorded at baseline. Patients were classified into three groups according to Hb levels: 15,606 patients (86.2%) into the no anemia group (male Hb≥130 g/L; female Hb≥120 g/L), 1800 (9.9%) with mild anemia (male 110≤Hb<129 g/L; female 110≤Hb<119 g/L), and 700 (3.9%) with moderate to severe anemia (Hb≤109 g/L). Multivariable Cox regression models were used to determine if anemia was independently associated with all‐cause death, cardiovascular death, or major bleeding, after adjusting for confounders. Anemia was present in 13.8% of the population at baseline. During a median follow‐up of 4.01 years, the incidences of all‐cause death (1.8, 4.9, and 8.9 per 100 person‐years), cardiovascular death (1.0, 2.9, and 4.5 per 100 person‐years), and major bleeding (0.5, 0.6, and 0.7 per 100 person‐years) were gradually accentuated in patients with no anemia, mild anemia, and moderate to severe anemia, respectively. Compared with patients with no anemia, those with anemia had higher risks for all‐cause death (mild anemia; adjusted hazard ratio [HR]: 1.22, 95% confidence interval [CI]: 1.08–1.38; moderate to severe anemia; adjusted HR: 1.53, 95% CI: 1.31–1.77); and cardiovascular death (mild anemia; adjusted HR: 1.29, 95% CI: 1.10–1.52; moderate to severe anemia; adjusted HR: 1.27, 95% CI: 1.03–1.57), but not for major bleeding. The association between anemia and all‐cause death was similar among subgroups stratified by sex, kidney function, anticoagulant, or ablation therapy. Conclusions Anemia was associated with increased risks of all‐cause death, cardiovascular death, but no major bleeding in AF patients. The effect of anemia correction on the prognosis of patients with AF requires further study.
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Affiliation(s)
- Zhuxin Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Chao Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Yu Bai
- Faculty of Science, The University of Sydney, Sydney, Australia
| | - Jiahui Wu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Rong Hu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Qiang Lv
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Man Ning
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Li Feng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China.,Heart Health Research Center, Beijing, China.,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, UK
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
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10
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Arita T, Suzuki S, Nagai K, Tanaka T, Nagahama T, Yagi N, Otsuka T, Yamashita T. Current Status of Catheter Ablation for Atrial Fibrillation in Japan. Int Heart J 2021; 62:997-1004. [PMID: 34544976 DOI: 10.1536/ihj.21-087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Catheter ablation for atrial fibrillation (AF) has been an established and frequently utilized approach in a variety of clinical settings. Nevertheless, real-world data about the clinical course of AF patients after initial catheter ablation remain limited, and these are mainly derived from particular registries or selected high-volume centers.In this study, we used health check-ups and insurance claims database from a Japanese insurance organization. The study population was comprised of 1777 patients who underwent catheter ablation for AF before June 2016. During the 3-year follow-up period, 396 (22.3%) patients underwent at least one repeated AF ablation, while 74 (4.2%) underwent two or more repeated ablations. In multivariate Cox regression analysis, longer time after AF diagnosis (7-11 months and ≥12 months versus 1-6 months) (HR, 1.05; 95% CI, 1.01-1.08 and HR, 1.04; 95% CI 1.02-1.07) was independently associated with repeated ablation. The discontinuation rates of OACs and AADs after the first ablation were 26.7% and 63.0% at 3 months and 75.2% and 89.1% at 1 year after the initial ablation, respectively. The former was independently associated with shorter time after AF diagnosis and lower diastolic blood pressure, whereas the latter was independently associated with older age, smaller CHADS2 score, and shorter time after AF diagnosis.We presented real-world data regarding the clinical course of young Japanese AF patients after initial catheter ablation based on a claims database in Japan.
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Affiliation(s)
- Takuto Arita
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | | | | | | | - Naoharu Yagi
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute
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11
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Impact of sinus rhythm maintenance on major adverse cardiac and cerebrovascular events after catheter ablation of atrial fibrillation: insights from AF frontier ablation registry. Heart Vessels 2021; 37:327-336. [PMID: 34524497 DOI: 10.1007/s00380-021-01929-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
The impact of catheter ablation for atrial fibrillation (AF) on cardiovascular events and mortality is controversial. We investigated the impact of sinus rhythm maintenance on major adverse cardiac and cerebrovascular events after AF ablation from a Japanese multicenter cohort of AF ablation. We investigated 3326 consecutive patients (25.8% female, mean age 63.3 ± 10.3 years) who underwent catheter ablation for AF from the atrial fibrillation registry to follow the long-term outcomes and use of anti coagulants after ablation (AF frontier ablation registry). The primary endpoint was a composite of stroke, transient ischemic attack, cardiovascular events, and all-cause death. During a mean follow-up of 24.0 months, 2339 (70.3%) patients were free from AF after catheter ablation, and the primary composite endpoint occurred in 144 (4.3%) patients. The AF nonrecurrence group had a significantly lower incidence of the primary endpoint (1.8 per 100 person-years) compared with the AF recurrence group (3.0 per 100 person-years, p = 0.003). The multivariate analysis revealed that freedom from AF (hazard ratio 0.61, 95% confidence interval 0.44-0.86, p = 0.005) was independently associated with the incidence of the composite event. In the multicenter cohort of AF ablation, sinus rhythm maintenance after catheter ablation was independently associated with lower rates of major adverse cardiac and cerebrovascular events.
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12
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Cappato R, Ali H. Surveys and Registries on Catheter Ablation of Atrial Fibrillation: Fifteen Years of History. Circ Arrhythm Electrophysiol 2021; 14:e008073. [PMID: 33441001 DOI: 10.1161/circep.120.008073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surveys and registries are widely used in medicine as valuable tools to integrate the information from randomized and observational studies. Early after its introduction in daily practice and parallel to its escalating popularity, catheter ablation of atrial fibrillation has been the subject of several surveys and registries. Over the years, relevant aspects associated with atrial fibrillation ablation have been investigated using these tools, including procedural safety and efficacy, discontinuation of anticoagulation therapy and risk of stroke postablation, and outcomes in special populations. The aim of this article is to provide a comprehensive review of the contributions offered by surveys and registries in catheter ablation of atrial fibrillation over the past 15 years.
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Affiliation(s)
- Riccardo Cappato
- Arrhythmia and Electrophysiology Center, IRCCS - MultiMedica Group, Milan, Italy
| | - Hussam Ali
- Arrhythmia and Electrophysiology Center, IRCCS - MultiMedica Group, Milan, Italy
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13
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Chew D, Piccini JP. Long-term oral anticoagulant after catheter ablation for atrial fibrillation. Europace 2021; 23:1157-1165. [PMID: 33400774 DOI: 10.1093/europace/euaa365] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/11/2020] [Indexed: 11/14/2022] Open
Abstract
Catheter ablation is superior to antiarrhythmic therapy for the reduction of symptomatic atrial fibrillation (AF), recurrence, and burden. The possibility of a true 'rhythm' control strategy with catheter ablation has re-opened the debate on rate vs. rhythm control and the subsequent impact on stroke risk. Some observation studies suggest that successful AF catheter ablation and maintenance of sinus rhythm are associated with a decrease in stroke risk, while the CABANA trial had demonstrated no apparent reduction. Other observational studies have demonstrated increased stroke risk when oral anticoagulation (OAC) is discontinued after catheter ablation. When and in whom OAC can be discontinued after ablation will need to be determined in properly conducted randomized control trials. In this review article, we discuss our current understanding of the interactions between AF, stroke, and anticoagulation following catheter ablation. Specifically, we discuss the evidence for the long-term anticoagulation following successful catheter ablation, the potential for OAC discontinuation with restoration of sinus rhythm, and novel approaches to anticoagulation management post-ablation.
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Affiliation(s)
- Derek Chew
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.,Division of Cardiology, Duke University Medical Center, 200 Morris Street, Durham, NC 27701, USA
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14
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Wakamatsu Y, Nagashima K, Watanabe R, Arai M, Yokoyama K, Matsumoto N, Otsuka T, Suzuki S, Hirata A, Murakami M, Takami M, Kimura M, Fukaya H, Nakahara S, Kato T, Hayashi H, Iwasaki YK, Shimizu W, Nakajima I, Harada T, Koyama J, Okumura K, Tokuda M, Yamane T, Tanimoto K, Momiyama Y, Nonoguchi N, Soejima K, Ejima K, Hagiwara N, Harada M, Sonoda K, Inoue M, Kumagai K, Hayashi H, Yazaki Y, Satomi K, Watari Y, Okumura Y. Clinical Outcomes of Off-Label Underdosing of Direct Oral Anticoagulants After Ablation for Atrial Fibrillation. Int Heart J 2020; 61:1165-1173. [DOI: 10.1536/ihj.20-335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yuji Wakamatsu
- Division of Cardiology, Nihon University Itabashi Hospital
| | | | - Ryuta Watanabe
- Division of Cardiology, Nihon University Itabashi Hospital
| | - Masaru Arai
- Division of Cardiology, Nihon University Itabashi Hospital
| | | | | | | | - Shinya Suzuki
- Department of Cardiology, The Cardiovascular Institute
| | - Akio Hirata
- Cardiovascular Division, Osaka Police Hospital
| | | | | | | | | | | | | | | | | | | | | | - Tomoo Harada
- St. Marianna University School of Medicine Hospital
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital
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15
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Iso K, Nagashima K, Arai M, Watanabe R, Yokoyama K, Matsumoto N, Otsuka T, Suzuki S, Hirata A, Murakami M, Takami M, Kimura M, Fukaya H, Nakahara S, Kato T, Hayashi H, Iwasaki YK, Shimizu W, Nakajima I, Harada T, Koyama J, Okumura K, Tokuda M, Yamane T, Tanimoto K, Momiyama Y, Nonoguchi N, Soejima K, Ejima K, Hagiwara N, Harada M, Sonoda K, Inoue M, Kumagai K, Hayashi H, Yazaki Y, Satomi K, Watari Y, Okumura Y. Clinical outcomes of ablation versus non-ablation therapy for atrial fibrillation in Japan: analysis of pooled data from the AF Frontier Ablation Registry and SAKURA AF Registry. Heart Vessels 2020; 36:549-560. [PMID: 33236221 DOI: 10.1007/s00380-020-01721-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/23/2020] [Indexed: 11/27/2022]
Abstract
Whether ablation for atrial fibrillation (AF) is, in terms of clinical outcomes, beneficial for Japanese patients has not been clarified. Drawing data from 2 Japanese AF registries (AF Frontier Ablation Registry and SAKURA AF Registry), we compared the incidence of clinically relevant events (CREs), including stroke/transient ischemic attack (TIA), major bleeding, cardiovascular events, and death, between patients who underwent ablation (n = 3451) and those who did not (n = 2930). We also compared propensity-score matched patients (n = 1414 in each group). In propensity-scored patients who underwent ablation and those who did not, mean follow-up times were 27.2 and 35.8 months, respectively. Annualized rates for stroke/TIA (1.04 vs. 1.06%), major bleeding (1.44 vs. 1.20%), cardiovascular events (2.15 vs. 2.49%) were similar (P = 0.96, 0.39, and 0.35, respectively), but annualized death rates were lower in the ablation group than in the non-ablation group (0.75 vs.1.28%, P = 0.028). After multivariate adjustment, the risk of CREs was statistically equivalent between the ablation and non-ablation groups (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.71-1.11), but it was significantly low among patients who underwent ablation for paroxysmal AF (HR 0.68 [vs. persistent AF], 95% CI 0.49-0.94) and had a CHA2DS2-VASc score < 3 (HR 0.66 [vs. CHA2DS2-VASc score ≥ 3], 95% CI 0.43-0.98]). The 2-year risk reduction achieved by ablation may be small among Japanese patients, but AF ablation may benefit those with paroxysmal AF and a CHA2DS2-VASc score < 3.
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Affiliation(s)
- Kazuki Iso
- Division of Cardiology, Department of Medicine, Itabashi Hospital, Nihon University School of Medicine, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Itabashi Hospital, Nihon University School of Medicine, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Masaru Arai
- Division of Cardiology, Department of Medicine, Itabashi Hospital, Nihon University School of Medicine, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Itabashi Hospital, Nihon University School of Medicine, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | | | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Takayuki Otsuka
- Department of Cardiology, The Cardiovascular Institute, Tokyo, Japan
| | - Shinya Suzuki
- Department of Cardiology, The Cardiovascular Institute, Tokyo, Japan
| | - Akio Hirata
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | - Masato Murakami
- Divison of Cardiology, Shonan-Kamakura General Hospital, Kanagawa, Japan
| | | | - Masaomi Kimura
- Department of Cardiology, Hirosaki University Hospital, Aomori, Japan
| | | | - Shiro Nakahara
- Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | | | | | | | | | - Ikutaro Nakajima
- St. Marianna University School of Medicine Hospital, Kanagawa, Japan
| | - Tomoo Harada
- St. Marianna University School of Medicine Hospital, Kanagawa, Japan
| | | | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Michifumi Tokuda
- Tokyo Jikei University School of Medicine Hospital, Tokyo, Japan
| | - Teiichi Yamane
- Tokyo Jikei University School of Medicine Hospital, Tokyo, Japan
| | - Kojiro Tanimoto
- National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | | | | | | | | | | | | | | | - Masaru Inoue
- Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | | | | | | | | | | | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Itabashi Hospital, Nihon University School of Medicine, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
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16
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Inoue K, Hirao K, Kumagai K, Kimura M, Miyauchi Y, Tsushima E, Ohishi M, Kimura K, Yasaka M, Yamaji H, Okawa K, Fujimoto M, Morishima I, Mine T, Shimizu W, Ohe M, Okumura K. Long-term efficacy and safety of anticoagulation after atrial fibrillation ablation: data from the JACRE registry. J Cardiol 2020; 77:263-270. [PMID: 33011056 DOI: 10.1016/j.jjcc.2020.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/18/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Catheter ablation (CA) is an important strategy for managing atrial fibrillation (AF). However, long-term anticoagulation strategies and clinical outcomes following CA, including thromboembolism and bleeding, have not yet been elucidated. METHODS We established a prospective registry, called the JACRE registry, for patients on rivaroxaban or warfarin administration who received CA for AF. The outcomes up to 30 days following the procedure were reported previously. The present study involved longer follow-up of patients enrolled in this registry to evaluate long-term anticoagulation strategies and clinical outcomes. RESULTS Data of 975 patients (rivaroxaban, n = 823; warfarin, n = 152) were collected from 27 institutes. Patient population had mean age 63.7 ± 10.3 years, 710 (72.8%) males, mean CHA2DS2-VASc score 1.9 ± 1.5, and mean follow-up period 28.7 ± 12.7 months after the index procedure. Anticoagulants were continued in 496 (50.9%) patients during the follow-up. Thromboembolism occurred in 3 patients, hemorrhagic stroke in 5, and major bleeding events in 9 (annualized event rate, 0.13%, 0.22%, and 0.40% per patient-year, respectively). There were no differences in the composite event rate of thromboembolism and International Society on Thrombosis and Haemostasis major bleeding between rivaroxaban and warfarin cohorts (0.53% and 0.55% per patient-year, respectively). CONCLUSIONS Long-term incidence of thromboembolism was extremely low in patients with AF treated with CA, while that of major bleeding was not especially low. Clinical Trials Registry: UMIN000032829 / UMIN000032830.
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Affiliation(s)
- Koichi Inoue
- Cardiovascular Center, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan.
| | - Kenzo Hirao
- Arrhythmia Advanced Therapy Center, AOI Universal Hospital, Kawasaki, Japan
| | | | - Masaomi Kimura
- Division of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital, Inzai, Japan
| | - Eiki Tsushima
- Hirosaki University Graduate School of Health Sciences, Hirosaki, Japan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Kagoshima University, Kagoshima, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Hirosuke Yamaji
- Heart Rhythm Center, Department of Cardiovascular Medicine, Okayama Heart Clinic, Okayama, Japan
| | - Keisuke Okawa
- Department of Cardiology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Manabu Fujimoto
- Department of Cardiology, Kouseiren Takaoka Hospital, Takaoka, Japan
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Takanao Mine
- Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Masatsugu Ohe
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
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