Atrial Fibrillation Ablation

Effectiveness and Safety of Antithrombotic Medication in Patients With Atrial Fibrillation and Atrial Fibrillation: Systematic Review and Meta-Analysis.

Posted by

0


BACKGROUND: For patients with atrial fibrillation who survive an intracranial hemorrhage (ICrH), the decision to offer oral anticoagulation (OAC) is challenging and necessitates balancing risk of thromboembolic events with risk of recurrent ICrH.

METHODS: This systematic review assesses the effectiveness and safety of OAC and/or antiplatelets in patients with atrial fibrillation with nontraumatic ICrH. Bibliographic databases CENTRAL, MEDLINE, EMBASE, and CINAHL were searched. Articles on adults with atrial fibrillation with spontaneous ICrH (intracerebral, subdural, and subarachnoid), receiving antithrombotic therapy for stroke prevention were eligible for inclusion.

RESULTS: Twenty articles (50 470 participants) included 2 randomized controlled trials (n=304)’ 8 observational studies, 8 cohort studies, and 2 studies that meta-analyzed individual-level data from observational studies. OAC therapy was associated with a significant reduction in thromboembolic events (summary relative risk [sRR], 0.51 [95% CI, 0.30-0.86], heterogeneity I2=2%; P=0.39, n=5 studies) and all-cause mortality (sRR, 0.52 [95% CI, 0.38-0.71], heterogeneity I2=0; P=0.44, n=3 studies). OAC therapy was not associated with an increased risk of recurrent ICrH (sRR, 1.44 [95% CI, 0.38-5.46], heterogeneity I2=70%, P=0.02, n=5 studies). Nonvitamin K antagonist OACs were more effective at reducing the risk of thromboembolic events (sRR, 0.65 [95% CI, 0.44-0.97], heterogeneity I2=72%, P=0.03, n=3 studies) and were associated with a lower risk of recurrent ICrH (sRR, 0.52 [95% CI, 0.40-0.67], heterogeneity I2=0%, P=0.43, n=3 studies) than warfarin.

CONCLUSIONS: In nontraumatic ICrH survivors with atrial fibrillation, OAC therapy is associated with a reduced risk of thromboembolic events and all-cause mortality without significantly increasing risk of recurrent ICrH. This finding is primarily based on observational data, and further larger randomized controlled trials are needed to corroborate or refute these findings.

Dabigatran Associated with Increased Bleeding During Atrial Fibrillation Ablation

Posted by

0


Until the effects of dabigatran use during ablation are clearer, it should be withheld for at least 24 hours before the procedure.

In warfarin recipients with therapeutic international normalized ratios (INRs), uninterrupted warfarin treatment during radiofrequency ablation for atrial fibrillation (AF) has relatively convincingly been shown to reduce both thromboembolic and bleeding events. Dabigatran is increasingly prescribed as an alternative to warfarin in patients with nonvalvular AF. However, dabigatran’s half life ranges from 12 to 14 hours and is prolonged in patients with renal insufficiency. Given the lack of an antidote to reverse its effects, the drug’s safety and efficacy during ablation are not clear.

Investigators used prospective data from a multicenter registry to compare the results of AF ablation in 145 patients taking dabigatran with the results in a matched cohort of 145 warfarin recipients with therapeutic INRs. Dabigatran was withheld on the day of surgery and restarted 3 hours after ablation; warfarin treatment was uninterrupted. The rate of major bleeding (pericardial tamponade) was 6% with dabigatran and 1% with warfarin (P=0.009). The rate of thromboembolic complications was also higher with dabigatran than with warfarin (2% vs. 0%), but this difference was not statistically significant.

Comment: These findings are by no means definitive. All of the warfarin patients had therapeutic international normalized ratios — a more realistic control group would have been a matched sample of all warfarin recipients. The optimal role of dabigatran in patients with atrial fibrillation undergoing ablation has yet to be determined. We need more data before we open the floodgates, and an editorialist describes a number of alternative strategies for anticoagulation during AF ablation. Still, this report does provide some practical guidance: Dabigatran should be discontinued before the day of the ablation, probably for at least 24 hours.

Source: Journal Watch Cardiology