Contemporary Management of Direct Oral Anticoagulants During Cardioversion and Ablation for Nonvalvular Atrial Fibrillation

Abstract

As overall prevalence of atrial fibrillation (AF) continues to rise, the number of patients who undergo ablation, or electrical/chemical cardioversion, to restore normal sinus rhythm continues to increase as well. As direct oral anticoagulants (DOACs) have continued to be incorporated into clinical practice for long‐term anticoagulation for AF, experience with how best to manage use of DOACs during electrophysiologic procedures is evolving. This review is intended to provide health care providers with a summary of current evidence regarding the use of DOACs during cardioversion and catheter ablation and provide key considerations for their use during such electrophysiologic procedures. PubMed and MEDLINE were searched from inception through June 2018 for studies in humans comparing DOACs alone or against vitamin K antagonists (VKAs) in adult patients (> 18 yrs) who underwent cardioversion or AF catheter ablation using the following key words: “rivaroxaban,” “dabigatran,” “apixaban,” “edoxaban,” “non–vitamin K antagonists,” “direct or new oral anticoagulants,” “warfarin,” “vitamin K antagonists,” “cardioversion,” “ablation of atrial fibrillation,” “uninterrupted,” and “catheter ablation.” Four retrospective studies and three prospective trials comparing DOACs with VKA in patients undergoing cardioversion and three prospective studies in patients undergoing catheter ablation for AF were identified. Observational data and meta‐analyses were also critically reviewed. Prospective trials to date suggest similar efficacy and safety with using DOACs in the setting of cardioversion and AF ablation compared to traditional therapy with VKA, with or without bridging. Injectable anticoagulant overlap can be avoided in patients receiving DOACs in the setting of cardioversion for AF. Minimal interruption in anticoagulation may be only necessary for AF ablation in those with highest bleeding risk, such as in renal dysfunction and where drug‐drug interactions may increase risk for anticoagulant accumulation. Periprocedural advantages of DOACs include convenience, rapid and predictable onset of effect, improved patient satisfaction, and potential for reduced costs.

Prognostic value of pharmacotherapy in patients with atrial fibrillation after radiofrequency ablation

“…Direct anticoagulants were used during the selection of patients for the study in peri-procedural period for the time of hospitalization, anticoagulant therapy continued after discharge from the hospital both with warfarin and a group of non-vitamin K antagonist oral anticoagulants, predominantly the latter. Trujillo T. C. et al [13] in a large meta-analysis showed the same efficiency and safety of direct anticoagulants and vitamin K antagonists, but the authors noted that direct anticoagulants had more predictable beginning and completion of activity, therefore they had advantages in patients at risk factors of bleeding. Recently, data on the safety of continuous or minimally interrupted use of non-vitamin K antagonist oral anticoagulants in peri-procedural period have been under active consideration [14].…”

Management of Direct Oral Anticoagulants in Patients with Atrial Fibrillation Undergoing Cardioversion

“…In this clinical situation, current guidelines recommend therapeutic anticoagulation for at least 3 weeks before and at least 4 weeks after cardioversion [12,13,14] (see Figure 1). It is important to underline that the highest risk of thromboembolism is within the first 7 days after cardioversion (>80% of events) with the greatest risk within the first 72 h [15]. An embolic event after cardioversion can be due both to the fact of left atrial thrombi migration or to the subsequent formation and migration of de novo thrombi caused by postcardioversion atrial stunning [8].…”

“…An embolic event after cardioversion can be due both to the fact of left atrial thrombi migration or to the subsequent formation and migration of de novo thrombi caused by postcardioversion atrial stunning [8]. The single biggest risk factor for thrombus formation is inadequate anticoagulation [1,12,13,14,15,16]. In the current European Society of Cardiology (ESC) Guidelines for the management of AF [12], the recommendation for anticoagulation with warfarin before cardioversion is in first class for a time ≥3 weeks and must be continued for ≥4 weeks after the procedure, based on pathophysiological and observational data [12].…”