“The prevailing consensus is that oral anticoagulation should be continued for at least 2 to 3 months after a successful ablation,” says Peter A. Noseworthy, MD. “However, AF patients often do not want to take long-term anticoagulants and assume they can discontinue taking these medications after undergoing catheter ablation.”

Taking a Closer Look

For a study published in the Journal of the American Heart Association, Dr. Noseworthy, Xiaoxi Yao, PhD, and colleagues examined oral anticoagulant practice patterns after ablation for AF. Using a national administrative claims database of nearly 7,000 patients undergoing catheter ablation for AF in the United States, the investigators looked at the rates and timing of oral anticoagulant discontinuation, and the extent of non–vitamin K oral anticoagulant use. The authors also assessed the impact of oral anticoagulant discontinuation on short‐ and long‐term risks of stroke, transient ischemic attacks (TIA), and systemic embolisms. The effect of time off from oral anticoagulants was assessed (stratified by patient risk using CHA2DS2‐VASc scores) on the risk of cardioembolism.

According to the results, about 1% of patients in the study suffered an ischemic stroke, TIA, or systemic embolism. Overall, about 25% of strokes occurred in the first 3 months after ablation, whereas about 22% occurred between 3 and 12 months and more than 53% occurred more than 12 months after ablation.

Non–vitamin K oral anticoagulant use among patients undergoing catheter ablation for AF increased over the study period and are now more commonly used than warfarin. In addition, non–vitamin K oral anticoagulants appeared to comparable to warfarin in terms of stroke prevention after AD ablation. However, about 73% of patients had incomplete anticoagulation in the first 3 months after ablation and about 69% had completely discontinued anticoagulation by 1 year.

“The overall rate of anticoagulant discontinuation was high in our analysis,” says Dr. Noseworthy. Importantly, any time off anticoagulation was associated with increased risk of stroke in the first three months. Beyond 3 months, discontinuation of oral anticoagulants was associated with higher rates of stroke or systemic embolism in high‐risk patients but not among those at lower risk.

Assessing Implications

Dr. Noseworthy says that findings from the study underscore the importance of not interrupting oral anticoagulant use for a minimum of 3 months and ensuring indefinite use for patients at higher risk of stroke, regardless of the apparent success of the ablation. “Many AF patients are stopping anticoagulation before the recommended 3‐month threshold after catheter ablation,” says Dr. Noseworthy. “Our findings highlight the importance of continuing anticoagulation to improve patient outcomes over the long term, especially for those at higher risk. Clinicians need to discuss the preferences for treatment with patients and ensure that they make informed decisions.”

Peter A. Noseworthy, MD, has indicated to Physician’s Weekly that he has no financial disclosures to report.

References

Noseworthy PA, Yao X, Deshmukh AJ, et al. Patterns of anticoagulation use and cardioembolic risk after catheter ablation for atrial fibrillation. J Am Heart Assoc. 2015;4: e002597. Available at: http://jaha.ahajournals.org/content/4/11/e002597.full.

Noseworthy PA, Kapa S, Deshmukh AJ, et al. Risk of stroke after catheter ablation versus cardioversion for atrial fibrillation: a propensity-matched study of 24,244 patients. Heart Rhythm. 2015;12:1154-1161.

January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;130:2071-2104.

Calkins H, Brugada J, Packer DL, et al. HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Heart Rhythm. 2007;4:816-861.