National Heart Foundation of Australia consensus statement on catheter ablation as a therapy for atrial fibrillation

Abstract

Atrial fibrillation (AF) is estimated to affect 1%-2% of the population. It is increasing in prevalence and is associated with excess mortality, considerable morbidity and hospitalisations. AF is responsible for a significant and growing societal financial burden. Catheter ablation is an increasingly used therapeutic strategy for the management of AF; however, some confusion exists among those caring for patients with this condition about the role and optimal use of ablative treatments for AF. Our aim in this consensus statement is to provide recommendations on the use of primary catheter ablation for AF in Australia, on the basis of current evidence. Our consensus is that the primary indication for catheter ablation of AF is the presence of symptomatic AF that is refractory or intolerant to at least one Class 1 or Class 3 antiarrhythmic medication. In selecting patients for catheter ablation of AF, consideration should be given to the patient's age, duration of AF, left atrial size and the presence of significant structural heart disease. Best results are obtained in younger patients with paroxysmal AF, no structural heart disease and smaller atria. Ablation techniques for patients with persistent AF are still undergoing evaluation. Discontinuation of warfarin or equivalent therapies is not considered a sole indication for this procedure. After AF ablation, anticoagulation therapy is generally recommended for all patients for at least 1-3 months. Discontinuation of warfarin or equivalent therapies after ablation is generally not recommended in patients who have a CHADS 2 score (congestive heart failure, hypertension, age ¿ 75 years, diabetes, 1 point each; prior stroke or transient ischaemic attack, 2 points) of ¿ 2.

Are left ventricular ejection fraction and left atrial diameter related to atrial fibrillation recurrence after catheter ablation?

“…[ 2 ] At present, although there are a variety of options for the treatment of AF, such as antiarrhythmic medication, surgical ablation, and catheter ablation, [ 3 – 5 ] catheter ablation is used as the first-line therapy by doctors and patients, [ 6 , 7 ] and it is increasingly being chosen as a therapeutic strategy for AF. [ 8 ] It is well known that AF recurrence is very common after catheter ablation and may decrease the probability of long-term success. [ 9 ] Studies have reported that several factors are related to AF recurrence after catheter ablation, such as obstructive sleep apnea, hypertension, age, sex, and obesity.…”

Anticoagulation for Atrial Fibrillation in Patients with End- Stage Kidney Disease

“…In addition to the CHADS 2 , the CHA 2 DS 2 -VASc acknowledges that stroke risk in patients with AF is related to age as a continuous variable, the higher risk of stroke in women, and incorporates risk associated with vascular disease, prior MI, complex aortic plaque, and peripheral arterial disease [18,20,22]. The CHA 2 DS 2 -VASc score states that antithrombotic therapy may be omitted for a score of 0, either oral anticoagulants, aspirin, or no antithrombotic therapy can be considered for a score of 1, and oral anticoagulation is recommended for patients with a prior stroke, TIA, or a score of 2 or more [3,9,15,16,18,20,[22][23][24][25][26]. Although CHADS 2 and CHA 2 DS 2 -VASc scores were useful tools in the past in assisting to quantify risk of stroke in patients with NVAF, recent studies have shown that the CHA 2 DS 2 -VASc score is only able to correctly predict strokes in approximately 68% of cases [3,18,22].…”

“…It has been shown, however, that patients with CKD and nonvalvular AF have a heightened stroke risk regardless of CHADS2DS2-VASc score, where 80% of patients having scores of ≥2 [29]. Current ACC/AHA/ESC guidelines advise that for a CHADS 2 score of ≥2 for either men or women, formal anticoagulation is recommended for patients [3,9,15,16,20,[22][23][24][25][26]30]. Those with a CHADS 2 score of 1, formal anticoagulation or aspirin alone should be considered in conjunction with patient specific comorbidities [3,9,15,16,20,[22][23][24][25][26].…”

“…Current ACC/AHA/ESC guidelines advise that for a CHADS 2 score of ≥2 for either men or women, formal anticoagulation is recommended for patients [3,9,15,16,20,[22][23][24][25][26]30]. Those with a CHADS 2 score of 1, formal anticoagulation or aspirin alone should be considered in conjunction with patient specific comorbidities [3,9,15,16,20,[22][23][24][25][26]. Finally, the guidelines state for patients with a CHADS 2 score of 0, no anticoagulation, neither formal nor antiplatelets, is recommended [3,9,15,16,20,[22][23][24][25][26].…”

“…Those with a CHADS 2 score of 1, formal anticoagulation or aspirin alone should be considered in conjunction with patient specific comorbidities [3,9,15,16,20,[22][23][24][25][26]. Finally, the guidelines state for patients with a CHADS 2 score of 0, no anticoagulation, neither formal nor antiplatelets, is recommended [3,9,15,16,20,[22][23][24][25][26]. In comparison with the American guidelines, the European guidelines recommend that males with a CHA 2 DS 2 -VASc score of ≥2 then anticoagulation should be used for stroke prevention, whereas those with a score of 1 should only be considered for anticoagulation, depending also on patient comorbidities and other risk factors [15,20,[22][23][24].…”