Systematic Review/Meta-analysis
Uninterrupted New Oral Anticoagulants Compared With Uninterrupted Vitamin K Antagonists in Ablation of Atrial Fibrillation: A Meta-analysis

https://doi.org/10.1016/j.cjca.2015.09.012Get rights and content

Abstract

Background

Use of uninterrupted vitamin K antagonists (VKAs) during ablation of atrial fibrillation is superior to bridging with heparin. Few studies evaluated the use of uninterrupted new oral anticoagulants (NOACs) during ablation of atrial fibrillation. These studies are relatively small in size and mostly underpowered to show differences in the infrequent thromboembolic complications between comparators.

Methods

We performed the first meta-analysis of uninterrupted NOAC compared with uninterrupted VKA in ablation of atrial fibrillation. We searched the online databases until May 2015 and report outcomes of interest as odds ratios (ORs) using a random effects model. A total of 3544 atrial fibrillation patients in 8 studies who underwent catheter ablation were included in this analysis.

Results

Overall, stroke and/or transient ischemic attack events were of very low incidence with uninterrupted anticoagulation strategy in 6 of 3544. There were no differences in rates of stroke and/or transient ischemic attack between uninterrupted NOAC and uninterrupted VKA, 0.11% vs 0.22% (OR, 0.65; 95% confidence interval [CI], 0.14-2.96; P = 0.58), nor in major bleeding 0.9% vs 1% (OR, 0.94; 95% CI, 0.48-1.87; P = 0.87). All bleeding 6.5% vs 7.3% (OR, 0.93; 95% CI, 0.67-1.29; P = 0.65), minor bleeding 6.3% vs 7.1% (OR, 0.93; 95% CI, 0.67-1.28), and cardiac tamponade 0.6% vs 0.6% (OR, 1.0; 95% CI, 0.43-2.31; P = 1.0) were all equal with uninterrupted NOACs compared with uninterrupted VKAs. Among 3544 patients, only one death occurred in the VKA group.

Conclusions

Use of uninterrupted NOACs in ablation appears to be as safe and efficacious as use of uninterrupted VKAs.

Résumé

Introduction

L’utilisation des antagonistes de la vitamine K (AVK) sans interruption lors de l’ablation de la fibrillation auriculaire est supérieure à la transition vers l’héparine. Peu d’études ont évalué l’utilisation des nouveaux anticoagulants oraux (NACO) sans interruption lors de l’ablation de la fibrillation auriculaire. Ces études sont de taille relativement petite et ont une puissance insuffisante pour montrer les différences dans les complications thromboemboliques rares entre les comparateurs.

Méthodes

Nous avons réalisé la première méta-analyse qui compare l’utilisation des NACO sans interruption à l’utilisation des AVK sans interruption lors de l’ablation de la fibrillation auriculaire. Nous avons cherché des données en ligne jusqu’en mai 2015 et rapporté les critères d’intérêt comme les ratios d’incidence approché (RIA) à l’aide du modèle à effets aléatoires. L’analyse a regroupé 8 études totalisant 3544 patients souffrant de fibrillation auriculaire qui avaient subi une ablation par cathéter.

Résultats

Dans l’ensemble, la stratégie d’anticoagulation sans interruption a entraîné une très faible incidence de l’accident vasculaire cérébral ou de l’ischémie cérébrale transitoire chez 6 des 3544 patients. Il n’y a eu aucune différence dans les taux d’accident vasculaire cérébral ou d’ischémie cérébrale transitoire entre l’utilisation des NACO sans interruption et l’utilisation des AVK sans interruption, 0,11 % vs 0,22 % (RIA, 0,65; intervalle de confiance [IC] à 95 %, 0,14-2,96; P = 0,58), ni dans les taux d’hémorragie grave 0,9 % vs 1 % (RIA, 0,94; IC à 95 %, 0,48-1,87; P = 0,87). Les taux de toutes les hémorragies 6,5 % vs 7,3 % (RIA, 0,93; IC à 95 %, 0,67-1,29; P = 0,65), de l’hémorragie minime 6,3 % vs 7,1 % (RIA, 0,93; IC à 95 %, 0,67-1,28) et de la tamponnade cardiaque 0,6 % vs 0,6 % (RIA, 1,0; IC à 95 %, 0,43-2,31; P = 1,0) entre l’utilisation des NACO sans interruption et l’utilisation des AVK sans interruption ont tous été égaux. Parmi les 3544 patients, seulement 1 décès a été observé dans le groupe d’AVK.

Conclusions

L’utilisation des NACO sans interruption lors d’ablation semble être aussi sûre et efficace que l’utilisation des AVK sans interruption.

Section snippets

Data sources and search strategy

We searched the online databases including PubMed, Cochrane CENTRAL, EMBASE, Web of Science, and CINAHL databases through May 2015 for observational and randomized studies published in English that compared uninterrupted NOAC with uninterrupted VKA in patients who underwent ablation of atrial fibrillation. Two reviewers (K.A., R.N.) identified studies that met the following inclusion criteria: (1) cohort and randomized studies published in the English language; (2) full-length article; (3)

Results

Our search strategy started with screening a total of 557 possible articles for inclusion. After excluding studies that did not meet inclusion and/or exclusion criteria, 8 studies were included in the final analysis (Fig. 1). Of those, only 1 study was a randomized controlled trial15 and the rest were observational studies.5, 6, 7, 16, 17, 18, 19 A total of 3544 atrial fibrillation patients who underwent ablation procedures were included in this analysis. Compared with the 1800 patients in the

Discussion

To our knowledge, this is the first meta-analysis to investigate safety and efficacy of uninterrupted anticoagulation periablation of atrial fibrillation, with a comparison of NOACs with VKAs and including 3544 patients, making it the largest report on the topic. Thromboembolic complications are of very low incidence, estimated to be < 1%, and with uninterrupted anticoagulation as in this analysis, it was 0.16%. This low event rate created a statistical challenge for studies comparing

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