Purpose: Transcatheter ablation (TA) has emerged as a promising therapeutic strategy for atrial fibrillation (AF), but the long-term use of oral anticoagulation therapy (OAT) after a successful procedure is still debatable. The aim of our study was to evaluate the long-term incidence of cerebral thromboembolic (TE) and haemorragic events according to the OAT strategy used in patients with AF undergoing TA. Methods: A total of 766 (612 males 79%, mean age 57±11 years) patients were included in this non-randomized, prospective observational study. The individual TE/haemorragic risk profile was evaluated by CHADS2, CHA2DS2VASc and HASBLED scores. OAT was discontinued in patients with CHADS2 ≤ 1 if no AF recurrences occurred, while OAT was maintained in patients with CHADS2 score ≥ 2, regardless of AF recurrences. TE/hemorragic events were recorded during follow-up. Results: Following TA 267 patients (34.9%, mean CHADS2 1.5) maintained OAT, while 499 patients (65.1%, mean CHADS2 1.3) discontinued OAT. During a mean follow-up of 63 months (± 28), the rate of ischemic stroke amongst Off-OAT patients was 0.20 per 100 patients year and 0.43 per 100 patients year in the On-OAT Group (p=0.150). Overall, 6 (2.2%) TE events occurred in the On-OAT group and 5 (1.0%) in the Off-OAT group (p=0,145). In all cases AF recurrence was recorded at the hospital admission. CHADS2 and CHA2DS2VASc scores ≥ 2 were statistically significant predictors of TE events (p=0.047 and p=0.020 respectively). Seven major hemorragic events occurred, all of them amongst On-OAT patients (7/267=2.6%). A HASBLED score ≥2 was associated with a higher incidence of hemorrhagic events (p=0.038). The overall incidence of TE/hemorrhagic events was 0.29 per 100 patients years. Conclusion: The overall incidence of TE events in this cohort of patients with AF undergoing TA was lower than in the general anticoagulated AF population. However considering the unpredictable nature of TE events, the routine use of CHADS2, CHA2DS2VASc and HASBLED scores should be recommended to guide decision about continuation or withdrawal of OAT following TA. Interestingly, all the TE events occurred during AF recurrences. Whether sinus rhythm maintenance by means of successful TA exert a protective role on TE events warrants future prospective randomized studies.
Oral anticoagulant therapy management after successful atrial fibrillation ablation.
CASTAGNO, Davide;GAITA, Fiorenzo
2013-01-01
Abstract
Purpose: Transcatheter ablation (TA) has emerged as a promising therapeutic strategy for atrial fibrillation (AF), but the long-term use of oral anticoagulation therapy (OAT) after a successful procedure is still debatable. The aim of our study was to evaluate the long-term incidence of cerebral thromboembolic (TE) and haemorragic events according to the OAT strategy used in patients with AF undergoing TA. Methods: A total of 766 (612 males 79%, mean age 57±11 years) patients were included in this non-randomized, prospective observational study. The individual TE/haemorragic risk profile was evaluated by CHADS2, CHA2DS2VASc and HASBLED scores. OAT was discontinued in patients with CHADS2 ≤ 1 if no AF recurrences occurred, while OAT was maintained in patients with CHADS2 score ≥ 2, regardless of AF recurrences. TE/hemorragic events were recorded during follow-up. Results: Following TA 267 patients (34.9%, mean CHADS2 1.5) maintained OAT, while 499 patients (65.1%, mean CHADS2 1.3) discontinued OAT. During a mean follow-up of 63 months (± 28), the rate of ischemic stroke amongst Off-OAT patients was 0.20 per 100 patients year and 0.43 per 100 patients year in the On-OAT Group (p=0.150). Overall, 6 (2.2%) TE events occurred in the On-OAT group and 5 (1.0%) in the Off-OAT group (p=0,145). In all cases AF recurrence was recorded at the hospital admission. CHADS2 and CHA2DS2VASc scores ≥ 2 were statistically significant predictors of TE events (p=0.047 and p=0.020 respectively). Seven major hemorragic events occurred, all of them amongst On-OAT patients (7/267=2.6%). A HASBLED score ≥2 was associated with a higher incidence of hemorrhagic events (p=0.038). The overall incidence of TE/hemorrhagic events was 0.29 per 100 patients years. Conclusion: The overall incidence of TE events in this cohort of patients with AF undergoing TA was lower than in the general anticoagulated AF population. However considering the unpredictable nature of TE events, the routine use of CHADS2, CHA2DS2VASc and HASBLED scores should be recommended to guide decision about continuation or withdrawal of OAT following TA. Interestingly, all the TE events occurred during AF recurrences. Whether sinus rhythm maintenance by means of successful TA exert a protective role on TE events warrants future prospective randomized studies.
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