Anticoagulation after catheter ablation of atrial fibrillation: An unnecessary evil? A systematic review and meta‐analysis

Abstract

Background Anticoagulation in patients with atrial fibrillation (AF) is currently based on clinical parameters (CHA2DS 2‐VASc score) that have been shown to predict cerebrovascular events (CVE). Controversy exists as to whether CVE risk persists unmodified after successful catheter ablation, as observational studies suggest a lower risk of CVE. Current guidelines recommend continued oral anticoagulation (OAC) based on the CHA 2DS 2‐VASc score risk profile. Methods We conducted a systematic literature review of all studies published up to July 31, 2018, that reported CVE after catheter ablation of AF and compared patients on or off OAC. Random‐effects models were used to demonstrate the risk of CVE and major bleeding in on‐OAC vs off‐OAC patients. This analysis was further stratified by CHADS2 and CHA 2DS 2‐VASc score. Results We retained 16 studies, 10 prospective cohort and 6 retrospective cohort, that met inclusion criteria, and which enrolled 25 177 patients: 13 166 off‐OAC and 12 011 on‐OAC. No significant difference in the incidence of CVE emerged between on‐OAC and off‐OAC patients after AF ablation (risk ratio, 0.66; confidence interval [CI], 0.38, 1.15). Similar results were found after stratification by CHADS2 and CHA 2DS 2‐VASc score. Off‐OAC patients suffered significantly less bleeding than those on OAC (RR, 0.17; CI, 0.09, 0.34). Of note, the percentage of patients with AF recurrence impacts the treatment effect in the two groups ( P = 0.001). Conclusions In this metanalysis, the risk‐benefit ratio favored the suspension of OAT after successful AF ablation even in patients at moderate‐high risk. Whether the reported results can be extended also to non‐vitamin K antagonist oral anticoagulants warrants further investigations.

Oral anticoagulation after catheter ablation of atrial fibrillation and the associated risk of thromboembolic events and intracranial hemorrhage: A systematic review and meta‐analysis

“…A second recent meta‐analysis by Proietti et al suggested a risk‐benefit ratio favoring discontinuation of OAC after successful CA of AF, even in patients at moderate‐high risk of TE, as they found no significant difference in risk of TE between patients at high‐risk vs those at intermediate‐to‐low risk of TE. This is the exact opposite of our results.…”

“…This is the exact opposite of our results. However, the findings of Proietti et al are limited as they did not include all available studies using CHA 2 DS 2 VASc in the analysis, including Gaita et al, Riley et al, and Själander et al only. This adversely impacts the accuracy of the results of Proietti et al, especially when assessing the RR for TE according to the CHA 2 DS 2 VASc score.…”

“…Reasons supporting this recommendation includes frequent recurrence of AF (both early and late), with a higher proportion of patients presenting with asymptomatic AF after CA . To add fuel to the controversy, in spite of these recommendations, two recent meta‐analysis showed no significant benefit on continuing OAC, even in patients with CHA 2 DS 2 VASc ≥ 2.…”

Recurrent ischemic stroke in patients with atrial fibrillation ablation and prior stroke: A study based on etiological classification

“…[13][14][15] This finding is supported by a comprehensive meta-analysis that clarified the efficacy and safety of OAC discontinuation after successful AF catheter ablation. 16 This meta-analysis of 25 177 patients who underwent catheter ablation from 16…”

Long‐term outcomes of catheter ablation for atrial fibrillation: It's a matter of time

“…The potential relationship between sinus rhythm maintenance and stroke risk have prompted some cardiac electrophysiologists to stop long‐term anticoagulation therapy, 9 despite the lack of randomized trial evidence confirming the safety of cessation of anticoagulation. In fact, the only randomized trial that evaluated the risk of stroke post‐AF ablation was CABANA and other evidence of stroke risk is provided from long‐term observational studies including a meta‐analysis that suggested that the risk of stroke was similar in patients who were discontinued or continued oral anticoagulation with a higher risk of bleeding in the latter 5,10 . The limited evidence for the association between AF ablation and stroke may be due to short follow up time in trials.…”