Efficacy and Safety of Non-Vitamin K Antagonist Oral Anticoagulants versus Vitamin K Antagonist Oral Anticoagulants in Patients Undergoing Radiofrequency Catheter Ablation of Atrial Fibrillation: A Meta-Analysis

Abstract

BackgroundUse of the non-vitamin K antagonist oral anticoagulants (NOACs) is endorsed by current guidelines for stroke prevention in patients with atrial fibrillation (AF). However efficacy and safety of NOACs in patients undergoing catheter ablation (RFCA) of AF has not been well established yet.ObjectivesTo perform a meta-analysis of all studies comparing NOACs and vitamin K antagonist oral anticoagulants (VKAs) in patients undergoing RFCA.Data SourcesStudies were searched for in PubMed and Google Scholar databases.Study Eligibility CriteriaStudies were considered eligible if: they evaluated the clinical impact of NOACs versus VKAs; they specifically analyzed the use of anticoagulants during periprocedural phase of RFCA; they reported clinical outcome data.Study Appraisal and Synthesis Methods25 studies were selected, including 9881 cases. The summary measure used was the risk ratio (RR) with 95% confidence interval (CI). The random-effects or the fixed effect model were used to synthesize results from the selected studies.ResultsThere was no significant difference in thromboembolic complications (RR 1.39; p=0.13). Bleeding complications were significantly lower in the NOACs-treated arm as compared to VKAs (RR=0.67, p<0.001). Interestingly, a larger number of thromboembolic events was found in the VKAs-treated arm in those studies where VKAs had been interrupted during the periprocedural phase (RR=0.68; p=ns). In this same subgroup a significantly higher incidence of both minor (RR=0.54; p=0.002) and major bleeding (RR=0.41; p=0.01) events was recorded. Conversely, the incidence of thromboembolic events in the VKAs-treated arm was significantly lower in those studies with uninterrupted periprocedural anticoagulation treatment (RR=1.89; p=0.02).LimitationsAs with every meta-analysis, no patients-level data were available.Conclusions and ImplicationsThe use of NOACs in patients undergoing RFCA is safe, given the lower incidence of bleedings observed with NOACs. On the other side, periprocedural interruption of VKAs and bridging with heparin is associated with a higher bleeding rate with no significant benefit on onset of thromboembolic events.

Long-term outcomes of coronary artery bypass grafting versus stent-PCI for unprotected left main disease: a meta-analysis

“…Small study effects were evaluated through graphical inspection of funnel plots, as already previously described [ 12 ]. Forest plots were used to graphically display the results of the meta-analysis, as already previously described [ 13 ]. Briefly, the measure of effect (OR) for each single study included (represented by a square) is plotted, together with confidence intervals, represented by horizontal lines.…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…W obserwacyjnych kohortach pacjentów poddawanych ablacji przezcewnikowej w doświadczonych ośrodkach, u których stosowano nieprzerwane leczenie za pomocą NOAC, nie uzyskano danych wskazujących na niekorzystny wpływ takiego postępowania na bezpieczeństwo leczenia [761,763,766,767]. Wyniki pierwszej kontrolowanej próby klinicznej, w której porównywano nieprzerwane leczenie za pomocą NOAC i VKA u pacjentów poddawanych ablacji AF, do której włączono ok. 200 osób, niedawno opublikowano [768], podobnie jak kilka doniesień z obserwacyjnych baz danych [761,769,770]. Trwają kolejne próby kliniczne służące porównaniu nieprzerwanego leczenia za pomocą VKA i NOAC u pacjentów z AF poddawanych ablacji, np.…”

The safety and efficacy of vitamin K antagonist in atrial fibrillation patients with previous ulcer bleeding

“…[9] Therefore, when estimating the clinical benefit of anticoagulation in AF patients, safety issue should be carefully addressed, as well as their efficacy. [10,11] Bleeding from the upper gastrointestinal tract is most common, [12] which negates the beneficial effect of VKA. [13] The main cause of upper gastrointestinal bleeding (GIB) is peptic ulcer.…”