Meta-analysis of controlled studies on minimally interrupted vs. continuous use of non-vitamin K antagonist oral anticoagulants in catheter ablation for atrial fibrillation

Abstract

Aims At present, there are no guideline recommendations for minimally interrupted use of non-vitamin K antagonist oral anticoagulants (mi-NOAC) during catheter ablation (CA) for atrial fibrillation (AF). Current evidence is predominantly based on observational studies, with continuous use of vitamin K antagonist in the control arm. This quantitative summary reflects the first high-level evidence on contemporary regimens, with continuous NOAC use (c-NOAC) as the current gold standard. Methods and results Meta-analysis (Pubmed, Embase, and Web of Science) on prospective, controlled studies comparing contemporary mi-NOAC (without bridging) with c-NOAC. Net adverse clinical events (major bleeding, thrombo-embolic events) were the primary outcome. In addition, we analysed total bleeding, minor bleeding, and silent cerebral embolism. Eight studies (six randomized, two observational) with 2168 patients were summarized. The primary endpoint occurred in 1.0% (18/1835): 1.1% (11/1005) vs. 0.8% (7/830) for the mi-NOAC and c-NOAC groups, respectively; odds ratio (OR) 1.20 [95% confidence interval (CI) 0.49–2.92, P = 0.64]. The OR for total bleeding on mi-NOAC was 1.26 (95% CI 0.97–1.63, P = 0.07). ORs for minor bleeding and silent cerebral embolism were 1.17 (95% CI 0.80–1.70, P = 0.34) and 2.62 (95% CI 0.54–12.61, P = 0.12), respectively. Conclusion This synopsis provides a quantitative synthesis of high-level evidence on a contemporary strategy of mi-NOAC in CA for AF, and overall clinical outcomes were not different from continuous NOAC use. Despite preprocedural interruption, there was no sign of lower bleeding rates. Additional higher volume datasets are warranted for more precise treatment effect estimations of this everyday alternative anticoagulation strategy in AF ablation.

Rhythm monitoring, success definition, recurrence, and anticoagulation after atrial fibrillation ablation: results from an EHRA survey

“…24 This risk reduction may be especially true for patients with a low CHA 2 DS 2 -VASc score, and access to continuous monitoring. 25,26 Accordingly, our respondents showed a tendency to terminate OAC in patients with paroxysmal AF and a low CHA 2 DS 2 -VASc score.…”

Cost-effectiveness of rhythm control strategy: Ablation versus antiarrhythmic drugs for treating atrial fibrillation in Korea based on real-world data

“…The possibility of overestimation cannot be excluded because of the asymptomatic embolic events that showed a high incidence after AF ablation in previous study ( 42 ). Recent meta-analysis reported that the incidence of silent cerebral embolism after AF ablation ranged from 10 to 24%, respectively ( 43 ). These are considered potential reasons.…”

Patient selection, peri-procedural management, and ablation techniques for catheter ablation of atrial fibrillation: an EHRA survey

“…Interestingly in patients on DOAC therapy, only 24.6% of the physicians would routinely perform AF ablation without interruption of DOAC therapy, despite recent studies and guidelines advocating AF ablation without interruption of DOAC therapy as a Class I recommendation. 4 , 26 …”

“…This change in clinical practice is probably supported by data demonstrating the safety of performing AF ablation without interruption of DOAC therapy and a potentially increased bleeding rate in patients who undergo heparin bridging. 3 , 26 The practice of performing AF ablation on uninterrupted anticoagulation therapy is also stated in recent guidelines and recommendations. 1 , 2 , 4 …”