Clinical Perspectives
Uninterrupted warfarin has been shown to be the most favorable anticoagulation management approach to reduce both thromboembolic and bleeding complications, especially in patients
Catheter ablation is a valid therapeutic option for treatment of atrial fibrillation (AF).1 The procedure is relatively complex, and often the outcome is related to the operator’s experience. Both bleeding and thromboembolic events are the most dangerous periprocedural complications.2, 3, 4, 5, 6
Periprocedural anticoagulation management with uninterrupted warfarin and a “therapeutic” international normalized ratio (INR) is the best approach for reducing both thromboembolic and bleeding complications, especially in patients with nonparoxysmal atrial fibrillation (NPAF).7, 8, 9 In addition, uninterrupted warfarin protects against silent cerebral ischemia (SCI).10
In recent years, novel oral anticoagulants (NOACs) have been introduced for prevention of stroke in patients with AF.11, 12, 13, 14 These drugs have shown noninferiority to warfarin in preventing stroke without increasing the bleeding risk. No randomized study evaluating the safety and feasibility of these drugs in the setting of AF ablation has been reported.15 Nonrandomized studies have evaluated the safety and feasibility of dabigatran and rivaroxaban in the setting of AF ablation.16, 17, 18, 19, 20, 21, 22, 23, 24, 25 Few data are available regarding apixaban (direct factor Xa inhibitor), the latest oral anticoagulant approved for preventing thromboembolism in patients with nonvalvular AF in the setting of AF ablation.15, 16
In this prospective multicenter study, we sought to evaluate the safety and feasibility of uninterrupted apixaban administration in the setting of catheter ablation for AF.
We performed a prospective multicenter registry of AF patients undergoing their first radiofrequency catheter ablation at 4 institutions in United States and Europe between June 2013 and July 2014 with uninterrupted apixaban administration. This was not a randomized controlled trial. The registry was approved by respective institutional review boards and informed consent was obtained from all patients.
The apixaban group comprised all consecutive patients who were taking twice daily 5- or 2.5-mg
A total of 400 patients (200 patients in the apixaban group, 200 patients in the warfarin group) were included in the study. The average age of the study population was 65.9 ± 9.9 years; 286 (71.5%) were male, and 66 patients (16.5%) had paroxysmal type AF. Baseline demographics, clinical parameters, and medication usage are listed in Table 1. There were no differences with regard to race, body mass index, hypertension, diabetes, prior stroke and/or TIA, coronary artery disease, heart failure,
This is the first prospective multicenter study showing that uninterrupted apixaban strategy (last dose taken the morning of the AF procedure) is feasible, safe, and not statistically different from uninterrupted warfarin in preventing periprocedural bleeding and thromboembolic complications during AF ablation. In addition, apixaban showed an important protection against SCI in a subset of patients.
These data are novel and important, especially in light of the fact that the majority of the
In our multicenter experience, uninterrupted apixaban administration (last dose taken on the morning of the procedure) in patients undergoing AF ablation seems to be feasible and effective in preventing clinical and silent thromboembolic events without increasing the risk of major bleedings.
Uninterrupted warfarin has been shown to be the most favorable anticoagulation management approach to reduce both thromboembolic and bleeding complications, especially in patientsClinical Perspectives
Dr. Di Biase is a consultant for Biosense Webster, Boston Scientific, and St. Jude Medical; and has received speaker honoraria/travel from Medtronic, AtriCure, EPiEP, and Biotronik. Dr. Natale has received speaker honoraria from Boston Scientific, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic; and is a consultant for Biosense Webster, St. Jude Medical, and Janssen. Dr. Burkhardt is a consultant for Stereotaxis, Biosense Webster, and Boehringer-Ingelheim.