A Prospective Randomized Trial of Apixaban Dosing During Atrial Fibrillation Ablation

Reynolds, Matthew R.; Allison, J. Scott; Natale, Andrea; Weisberg, Ian; Ellenbogen, Kenneth A.; Richards, Mark; Hsieh, Wen Hua; Sutherland, Julie; Cannon, Christopher P.

doi:10.1016/j.jacep.2017.11.005

Cited by 60 publications

(62 citation statements)

References 25 publications

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“…A total of 2694 records were identified, of which 29 studies met the predefined criteria and hence were included in the analysis. The detailed search flowchart was illustrated in Figure .…”

Section: Resultsmentioning

confidence: 99%

“…Of note, in that meta‐analysis, the efficacy and safety of interrupted NOACs vs interrupted VKAs were not specifically assessed. Furthermore, several studies have been published recently, among which the AEIOU study published online is a randomized cohort trial . Therefore, we comprehensively collected the published studies comparing NOACs and VKAs to evaluate the safety and efficacy of NOACs in AF patients undergoing catheter ablation and to investigate the differences in uninterrupted NOACs vs uninterrupted VKAs or interrupted NOACs vs interrupted VKAs.…”

Section: Introductionmentioning

confidence: 99%

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Safety and efficacy of nonvitamin K antagonist oral anticoagulants during catheter ablation of atrial fibrillation: A systematic review and meta‐analysis

Faggioni

Baber

et al. 2018

Cardiovascular Therapeutics

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“…A total of 2694 records were identified, of which 29 studies met the predefined criteria and hence were included in the analysis. The detailed search flowchart was illustrated in Figure .…”

Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Safety and efficacy of nonvitamin K antagonist oral anticoagulants during catheter ablation of atrial fibrillation: A systematic review and meta‐analysis

Faggioni

Baber

et al. 2018

Cardiovascular Therapeutics

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“…Another question is whether every NOAC is effective in preventing periprocedural thromboembolic complications. RCTs with dabigatran (RE-CIRCUIT) and rivaroxaban (VENTURE-AF) did not show any thromboembolic events [5,6], while RCTs with apixaban (AXAFA, AEIOU) showed a low thromboembolic event rate [12,21].…”

Section: Discussionmentioning

confidence: 98%

“…The ABlation peRIoperative DabiGatran in use Envisioning in Japan (ABRIDGE-J) randomized trial demonstrated that anticoagulation with minimally interrupted dabigatran (1 or 2 doses withheld) was associated with fewer ISTH major bleeding complications than uninterrupted VKA with no increase in thromboembolic events (Table 3) [13]. In addition, the Apixaban Evaluation of Interrupted Or Uninterrupted anticoagulation for ablation of atrial fibrillation (AEIOU) randomized trial showed no difference between continuous apixaban compared with minimally interrupted apixaban (1 dose withheld) with regard to major bleeding (BARC 3-5) or thromboembolic events (Table 3) [21]. Finally, a recent meta-analysis of 4 randomized and 9 prospective observational studies (N = 5463) found that minimally interrupted and continuous NOAC strategy were both safe and non-inferior strategies compared with uninterrupted VKA [14].…”

Section: Discussionmentioning

confidence: 99%

“…One of the reasons to choose an uninterrupted NOAC strategy instead of a minimally interrupted NOAC strategy is to maximally reduce the incidence of thromboembolic events. However, the risk of a systemic thromboembolic event using a minimally interrupted NOAC strategy is already low (< 0.7%) [13,14,21]. Furthermore, continuous anticoagulation does not prevent all acute brain lesions, which can be caused by debris from ablation lesions, air emboli, or small thrombi [22].…”

Section: Discussionmentioning

confidence: 99%

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Minimally interrupted novel oral anticoagulant versus uninterrupted vitamin K antagonist during atrial fibrillation ablation

Heide

Vroegh

Bhagwandien

et al. 2018

J Interv Card Electrophysiol

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Purpose The safety and efficacy of a minimally interrupted novel oral anticoagulant (NOAC) strategy at the time of atrial fibrillation (AF) ablation is uncertain. The purpose of this study was to compare rates of bleeding and thromboembolic events between minimally interrupted NOAC and uninterrupted vitamin K antagonist (VKA) in patients undergoing AF ablation. Methods This was a retrospective single-center cohort study of consecutive patients who underwent AF catheter ablation between January 2013 and April 2017. Endpoints included major bleeding, clinically relevant non-major bleeding and systemic thromboembolic event from the time of ablation through 30 days. Bleeding events were defined by the Bleeding Academic Research Consortium (BARC) and International Society on Thrombosis and Haemostasis (ISTH). Results A total of 637 patients were included in the analysis, 520 patients used uninterrupted VKA and 117 patients minimally interrupted NOAC (dabigatran: n = 68; apixaban: n = 30; rivaroxaban, n = 14; edoxaban, n = 5). The rate of clinically relevant non-major bleeding was lower in the NOAC group in comparison to the VKA group (BARC type 2: 2.6% versus 8.3%, P = 0.03; ISTH: 0% versus 3.8%, P = 0.03). Rates of major bleeding were similar between groups (BARC type 3 to 5: 3.4% versus 4.2%, P = NS; ISTH: 6.0% versus 8.7%, P = NS; for NOAC and VKA groups, respectively). Rates of systemic embolism were 0% with minimally interrupted NOAC, and 0.6% with uninterrupted VKA (P = NS). Conclusions In patients undergoing AF ablation, anticoagulation with minimally interrupted NOAC was associated with fewer clinically relevant non-major bleeding events in comparison with uninterrupted VKA without compromising thromboembolic safety.

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Perioperative Management of Patients Taking Direct Oral Anticoagulants

Douketis,

Spyropoulos

2024

JAMA

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ImportanceDirect oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism.ObservationsFor elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (&lt;6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure.Conclusions and RelevanceWhen patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.

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A Prospective Randomized Trial of Apixaban Dosing During Atrial Fibrillation Ablation

Cited by 60 publications

References 25 publications

Safety and efficacy of nonvitamin K antagonist oral anticoagulants during catheter ablation of atrial fibrillation: A systematic review and meta‐analysis

Safety and efficacy of nonvitamin K antagonist oral anticoagulants during catheter ablation of atrial fibrillation: A systematic review and meta‐analysis

Minimally interrupted novel oral anticoagulant versus uninterrupted vitamin K antagonist during atrial fibrillation ablation

Perioperative Management of Patients Taking Direct Oral Anticoagulants

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