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Sun Y, Liu X, Xu Y. Meta-analysis of efficacy and safety of new oral anticoagulants compared with warfarin in Japanese patients undergoing catheter ablation for atrial fibrillation. J Interv Card Electrophysiol 2020; 58:381-399. [PMID: 32458179 DOI: 10.1007/s10840-020-00784-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 05/15/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This meta-analysis was designed to evaluate the efficacy and safety of new oral anticoagulants (NOACs) for perioperative anticoagulation of atrial fibrillation (AF) catheter ablation (CA) in Japanese patients with non-valvular atrial fibrillation (NVAF). METHODS PubMed, Embase, Web of Science, and the Cochrane Library were searched for articles published up to June 30, 2019. Two reviewers independently screened literature, extracted data, and assessed the methodological quality of the included studies according to the inclusion and exclusion criteria. Then, meta-analysis was performed using RevMan 5.3 software. RESULTS Nineteen studies with a total of 6827 patients were included in this meta-analysis. The experimental group received dabigatran, rivaroxaban, apixaban, or edoxaban; the control group received warfarin. The safety endpoints were bleeding complications; the efficacy endpoints were thromboembolic complications. Results were as follows: Patients with NOACs had a lower risk of overall bleeding complications (OR = 0.69, 95% CI (0.54, 0.87), P = 0.002), including major bleeding complications (OR = 0.52, 95% CI (0.32, 0.84), P = 0.007) and minor bleeding complications (OR = 0.73, 95% CI (0.56, 0.94), P = 0.02). There was no significant difference in thromboembolic complications between NOACs and warfarin after CA (OR = 0.39, 95% CI (0.14, 1.10), P = 0.08). CONCLUSIONS In Japanese NVAF patients undergoing CA, NOACs have similar effects to warfarin in the prevention of stroke and systemic embolism. Moreover, NOACs were associated with a lower incidence of bleeding complications.
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Affiliation(s)
- Yuchao Sun
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Nanjing Medical University, #261 Huansha Road, Shangcheng District, Hangzhou, 310000, Zhejiang Province, China
| | - Xiaohua Liu
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Nanjing Medical University, #261 Huansha Road, Shangcheng District, Hangzhou, 310000, Zhejiang Province, China
| | - Yizhou Xu
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Nanjing Medical University, #261 Huansha Road, Shangcheng District, Hangzhou, 310000, Zhejiang Province, China.
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Ge Z, Faggioni M, Baber U, Sartori S, Sorrentino S, Farhan S, Chandrasekhar J, Vogel B, Qadeer A, Halperin J, Reddy V, Dukkipati S, Dangas G, Mehran R. Safety and efficacy of nonvitamin K antagonist oral anticoagulants during catheter ablation of atrial fibrillation: A systematic review and meta-analysis. Cardiovasc Ther 2018; 36:e12457. [PMID: 29971964 DOI: 10.1111/1755-5922.12457] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 12/13/2022] Open
Abstract
AIMS Catheter ablation for atrial fibrillation (AF) is associated with a transitory increase in the risk of both thromboembolic and bleeding events. Evidence on the use of nonvitamin K antagonist oral anticoagulants (NOACs) in patients undergoing AF ablation mostly comes from small observational studies, underpowered to detect differences in clinical outcomes between NOACs and vitamin K antagonists (VKAs) treated patients. This updated meta-analysis aimed to determine the safety and efficacy of periprocedural anticoagulation with NOACs compared with VKAs in AF patients undergoing catheter ablation. METHODS We searched MEDLINE, Cochrane library, and web sources for randomized and observational studies comparing periprocedural treatment with NOACs and VKAs in patients undergoing AF ablation. The primary safety endpoint was major bleeding events, and the primary efficacy endpoint was thromboembolic events (a composite of systemic thromboembolism, transient ischemic attack, and stroke). RESULTS A total of 29 studies with 12 644 patients were included in the meta-analysis. Overall, patients on NOACs had a significantly lower risk of major bleeding compared to VKAs either in observational studies (Peto OR 0.68; 95% CI: 0.48-0.95; P = 0.022; I2 = 20%) or in RCTs (Peto OR 0.30; 95% CI: 0.14-0.62; P = 0.001; I2 = 28%). Uninterrupted NOACs reduced the risk of major bleeding when compared to uninterrupted VKAs (Peto OR 0.66; 95% CI: 0.45-0.96; P = 0.028; I2 = 1%), similarly, interrupted NOACs lowered the risk of major bleeding compared to interrupted VKAs (Peto OR 0.29; 95% CI: 0.13-0.66; P = 0.003; I2 = 0%; Pinteraction = 0.076). The rate of thromboembolic complications was very low and did not significantly differ between the study groups either in observational studies (Peto OR 0.91; 95% CI: 0.49-1.67; P = 0.755; I2 = 0%) or in RCTs (Peto OR 0.14; 95% CI: 0.01-1.30; P = 0.083; I2 = 0%). CONCLUSIONS Use of NOACs compared to VKAs significantly reduced the risk of bleeding in patients with AF ablation. Similarly, the risk of bleeding was lower with uninterrupted NOACs than with uninterrupted VKAs, and with interrupted NOACs than with interrupted VKAs. The rate of thromboembolic complications was extremely low in both study groups without any differences.
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Affiliation(s)
- Zhen Ge
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York.,Division of cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Michela Faggioni
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Samantha Sartori
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Sabato Sorrentino
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Serdar Farhan
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Jaya Chandrasekhar
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Birgit Vogel
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Abdul Qadeer
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Jonathan Halperin
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Vivek Reddy
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Srinivas Dukkipati
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - George Dangas
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
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Ma CS. The Use of Direct Oral Anticoagulants for Prevention of Stroke and Systemic Embolic Events in East Asian Patients with Nonvalvular Atrial Fibrillation. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2018. [DOI: 10.15212/cvia.2017.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Periprocedural Management of Direct Oral Anticoagulants Surrounding Cardioversion and Invasive Electrophysiological Procedures. Cardiol Rev 2018; 26:245-254. [PMID: 29621010 PMCID: PMC6082596 DOI: 10.1097/crd.0000000000000188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Supplemental Digital Content is available in the text. As direct oral anticoagulants (DOACs) have demonstrated favorable efficacy and safety outcomes compared with vitamin K antagonists for the treatment and prevention of venous thromboembolism and the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, their role in the management of anticoagulation during electrophysiological procedures continues to evolve. At present, guidelines are limited regarding specific recommendations for the use of DOACs in these clinical settings. Here, we review available data regarding the risks and benefits associated with various periprocedural anticoagulation management approaches when patients receiving DOACs undergo electrophysiologic procedures including cardioversion, ablation, and device implantation. This discussion is intended to provide clinicians with an overview of available evidence and best practices to minimize the risk of both thromboembolic and bleeding events in the periprocedural setting.
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Tsyganov A, Shapieva A, Sandrikov V, Fedulova S, Mironovich S, Dzeranova A, Lyan E. Transesophageal vs. intracardiac echocardiographic screening in patients undergoing atrial fibrillation ablation with uninterrupted rivaroxaban. BMC Cardiovasc Disord 2017; 17:171. [PMID: 28662693 PMCID: PMC5492399 DOI: 10.1186/s12872-017-0607-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 06/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with atrial fibrillation (AF) routinely undergo different imaging modalities for the evaluation of the left atrial (LA) appendage to rule out thrombus prior to the AF ablation procedure. Recently, uninterrupted novel oral anticoagulants were introduced for patients undergoing atrial fibrillation (AF) ablation to minimize the peri-procedural thromboembolism risk. We performed a retrospective analysis to evaluate the safety of uninterrupted rivaroxaban and whether transesophageal (TEE) or intracardiac echocardiography (ICE) is necessary for patients undergoing AF ablation. METHODS Data from 332 consecutive patients (42% females, aged 64 ± 11 years) with AF undergoing either TEE (n = 115) prior to catheter ablation or ICE (n = 217) for the detection of LA thrombus were analyzed. All patients were on uninterrupted rivaroxaban during, and for at least, 4 weeks before the procedure. Heparin bolus was administered in all patients before transseptal puncture to maintain a target activated clotting time of >350 s. RESULTS A total of 277 patients (80.4%) had paroxysmal AF. The average CHA2DS2-VASc score was 2.11 ± 0.91 in the TEE group and 2.46 ± 0.61 in the ICE group. The CHA2DS2-VASc score was ≥2 in 64 (55.7%) and 214 (98.6%) patients in the TEE and ICE groups, respectively. The left atrial appendage was adequately visualized in all cases. None of the patients have an identifiable LA thrombus either in the TEE group or the ICE group. One (0.3%) thromboembolic periprocedural stroke occurred in a patient with long-standing persistent AF in the TEE group. CONCLUSIONS This study illustrates that performing AF ablation with ICE guidance on uninterrupted rivaroxaban for at least 4 weeks even without TEE is feasible and safe.
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Affiliation(s)
- A Tsyganov
- Cardiac Electrophysiology Department, Petrovsky National Research Centre of Surgery, Abrikosovsky per. 2, Moscow, 119991, Russia.
| | - A Shapieva
- Cardiac Electrophysiology Department, Petrovsky National Research Centre of Surgery, Abrikosovsky per. 2, Moscow, 119991, Russia
| | - V Sandrikov
- Department of Clinical Physiology, Radiology and Diagnostic Imaging, Petrovsky National Research Centre of Surgery, Abrikosovsky per. 2, Moscow, Russia
| | - S Fedulova
- Department of Clinical Physiology, Radiology and Diagnostic Imaging, Petrovsky National Research Centre of Surgery, Abrikosovsky per. 2, Moscow, Russia
| | - S Mironovich
- Cardiac Electrophysiology Department, Petrovsky National Research Centre of Surgery, Abrikosovsky per. 2, Moscow, 119991, Russia
| | - A Dzeranova
- Department of Clinical Physiology, Radiology and Diagnostic Imaging, Petrovsky National Research Centre of Surgery, Abrikosovsky per. 2, Moscow, Russia
| | - E Lyan
- Cardiac Electrophysiology Department, Mechnikov North-West State Medical University, Kirochnaya ul. 41, Saint Petersburg, 191015, Russia
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Risk of gastrointestinal bleeding with direct oral anticoagulants: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol 2017; 2:85-93. [DOI: 10.1016/s2468-1253(16)30162-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 12/31/2022]
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New oral anticoagulants compared to warfarin for perioperative anticoagulation in patients undergoing atrial fibrillation catheter ablation: a meta-analysis of continuous or interrupted new oral anticoagulants during ablation compared to interrupted or continuous warfarin. J Interv Card Electrophysiol 2017; 48:267-282. [DOI: 10.1007/s10840-016-0221-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 12/19/2016] [Indexed: 12/11/2022]
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Vallakati A, Sharma A, Madmani M, Reddy M, Kanmanthareddy A, Gunda S, Lakkireddy D, Lewis WR. Efficacy and Safety of Novel Oral Anticoagulants for Atrial Fibrillation Ablation: An Updated Meta-Analysis. Cardiol Ther 2016; 5:85-100. [PMID: 27105998 PMCID: PMC4906088 DOI: 10.1007/s40119-016-0061-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Novel oral anticoagulants (NOACs) have been approved for prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). A large number of patients are on NOACs when they present for AF ablation. We intended to evaluate the safety and efficacy of NOACs for AF ablation during the periprocedural period by performing a meta-analysis of trials comparing NOACs with warfarin. METHODS Studies comparing NOACs (dabigatran and rivaroxaban) with warfarin as periprocedural anticoagulants for AF ablation were identified using an electronic search. Primary outcomes were: (1) a composite endpoint of stroke, transient ischemic attack (TIA), peripheral arterial embolism, or silent cerebral lesions on magnetic resonance imaging (MRI) and (2) major bleeding complications. A random effects model was used to pool the safety and efficacy data across all included trials. RESULTS When compared to warfarin, there was an increased risk of the composite endpoint of stroke, TIA, peripheral arterial embolism, or silent cerebral lesions on MRI with NOACs as periprocedural anticoagulants for AF ablation [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.06-2.68]. Sub-group analysis revealed a higher risk of composite endpoint with dabigatran as a periprocedural anticoagulant for AF ablation (OR: 2.01, 95% CI: 1.19-3.39) whereas the risk was similar with rivaroxaban (OR: 0.90, 95% CI: 0.34-2.41). Sensitivity analysis after excluding silent cerebral lesions on MRI showed there was no increased risk of thromboembolic events with either dabigatran (OR: 1.69, 95% CI: 0.81-3.51) or rivaroxaban (OR: 0.70, 95% CI: 0.12-4.04). Risk of bleeding with NOACs was similar to warfarin (OR: 0.91, 95% CI: 0.62-1.34). CONCLUSION NOACs are comparable to warfarin in terms of bleeding complications. However, dabigatran therapy is potentially associated with a higher risk of silent cerebral lesions on MRI. The results of this study should be considered as hypothesis-generating and assessed further in prospective randomized clinical studies.
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Affiliation(s)
- Ajay Vallakati
- Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Abhishek Sharma
- Division of Cardiovascular Diseases, State University of New York, Downstate Medical Center, Brooklyn, NY, USA.
| | - Mohammed Madmani
- Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Madhu Reddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS, USA
| | - Arun Kanmanthareddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS, USA
| | - Sampath Gunda
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS, USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS, USA
| | - William R Lewis
- Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Sankaranarayanan R, Fox DJ. Are Some Anticoagulants More Equal Than Others? - Evaluating the Role of Novel Oral Anticoagulants in AF Ablation. Curr Cardiol Rev 2016; 12:330-335. [PMID: 27146837 PMCID: PMC5304256 DOI: 10.2174/1573403x12666160505113755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 04/22/2016] [Accepted: 04/26/2016] [Indexed: 12/02/2022] Open
Abstract
Left atrial ablation strategies are being increasingly performed as a Class 1 therapeutic indication for drug refractory paroxysmal atrial fibrillation (AF). Traditionally AF ablation has been performed with patients on uninterrupted warfarin therapy, however over the last few years, novel oral anticoagulants (NOACs) have emerged as attractive alternatives to warfarin in order to reduce stroke risk due to AF. NOACs are therefore increasingly being used instead of warfarin in the management of AF. There is also mounting evidence mainly in the form of small randomised studies and meta-analysis that have demonstrated that the use of NOACs for AF ablation is efficacious, safe and convenient. However the peri-procedural dosing protocols used in various studies especially in terms of whether NOAC use is interrupted or uninterrupted during AF ablation, have significant inter-operator and inter-institution variability. Currently there is also a lack of randomised controlled trials to validate the data obtained from meta-analyses. There is also evidence that use of NOACs may increase the requirement of unfractionated heparin during the procedure. This review article shall examine the currently available evidence-base, appraise the gaps in the current evidence and also underscore the need for larger randomised clinical trials in this rapidly developing field.
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Affiliation(s)
- Rajiv Sankaranarayanan
- University of Manchester and Northwest Heart Centre, University Hospital of South Manchester, Manchester, UK.
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Li PJ, Xiao J, Yang Q, Feng Y, Wang T, Liu GJ, Liang ZA. Network meta-analysis of efficacy and safety of competitive oral anticoagulants in patients undergoing radiofrequency catheter ablation of atrial fibrillation. J Interv Card Electrophysiol 2016; 46:213-24. [PMID: 27001171 DOI: 10.1007/s10840-016-0126-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 03/07/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this network meta-analysis was to evaluate the comparative efficacy and safety of dabigatran, rivaroxaban, apixaban, interrupted vitamin K antagonist (I-VKA), and continuous VKA (C-VKA) in patients undergoing radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). METHODS PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to identify clinical trials comparing dabigatran, rivaroxaban, or apixaban with I-VKA or C-VKA, or against each other, in AF patients undergoing RFCA. A network meta-analysis was conducted to directly and indirectly compare the efficacy and safety of competitive anticoagulation regimens with a Bayesian random-effects model. RESULTS A total of 39 studies enrolling 27,766 patients were included. C-VKA demonstrated significant superiority over I-VKA in reducing thromboembolic events (risk difference [RD] -0.0068, 95 % confidence interval [CI] -0.0106 to -0.0032) and major bleeding complications (RD -0.0044, 95 % CI -0.0098 to -0.0006). Rivaroxaban compared with I-VKA was associated with a lower risk of thromboembolism (RD -0.0073, 95 % CI -0.0134 to -0.0012), being at the best ranking position among all of the compared anticoagulation regimens in terms of both the efficacy and safety. None of the remaining comparisons reached statistically significant difference in the rate of thromboembolism or major bleeding. CONCLUSIONS The present study suggests that C-VKA is superior to I-VKA for AF patients undergoing RFCA. Rivaroxaban is the highest probability to be the optimal alternative to C-VKA among the three non-VKA oral anticoagulants in AF ablation.
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Affiliation(s)
- Pei-Jun Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, Sichuan, People's Republic of China, 610041
| | - Jun Xiao
- Department of Intensive Care Unit, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Qing Yang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Yuan Feng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Ting Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, Sichuan, People's Republic of China, 610041
| | - Guan-Jian Liu
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Zong-An Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu, Sichuan, People's Republic of China, 610041.
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Bleeding risks with novel oral anticoagulants during catheter ablation of atrial fibrillation: a systematic review and network meta-analysis. J Interv Card Electrophysiol 2015; 44:105-11. [PMID: 26342485 DOI: 10.1007/s10840-015-0053-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/26/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Comprehensive comparisons of safety (measured by bleeding risk) between multiple novel oral anticoagulants (NOACs and warfarin) in the peri-procedural period of catheter ablation (CA) for atrial fibrillation (AF) are rare. METHODS AND RESULTS MEDLINE, EMBASE, and COCHRANE LIBRARY were searched up to February 2015 by two reviewers independently. Predefined inclusion criteria identified 24 studies which were included in the analysis. Data were extracted by two researchers, and a network meta-analysis was conducted in R with R2WinBugS package, within Bayesian framework. Pooled odds ratios (OR) and 95% confidence intervals (CI) were summarized to evaluate the bleeding risks of three novel anticoagulants (dabigatran, rivaroxaban, apixaban) in AF patients undergoing catheter ablation (CA). With respect to total bleeding risk, no significant difference was observed between dabigatran, rivaroxaban, apixaban, and vitamin K antagonists (VKAs) by mixed-treatment comparison. The similar results were seen in the direct comparison. While dabigatran was associated with a lower rate of minor bleeding in comparison to VKAs (OR = 0.67 with 95%CI 0.49-0.93). CONCLUSIONS Risks of bleeding with dabigatran, rivaroxaban, apixaban, and VKAs were similar in peri-procedural period of CA for AF.
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Amara W, Fromentin S, Dompnier A, Nguyen C, Allouche E, Taieb J, Georger F, Saoudi N. New oral anticoagulants in patients undergoing atrial flutter radiofrequency catheter ablation: an observational study. Future Cardiol 2015; 10:699-705. [PMID: 25495812 DOI: 10.2217/fca.14.70] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Atrial flutter (AFL) ablation requires optimal periprocedural anticoagulation in order to minimize thromboembolic events/bleeding risk. This study describes the characteristics of patients receiving new oral anticoagulants before AFL ablation and assesses complications. METHODS This multicenter, retrospective study reports ischemic and hemorrhagic predischarge, postprocedural complications. RESULTS We evaluated 60 patients (62.3% male; mean age: 69.2 ± 9.7 years; CHA2DS2-VASc score: 2.44 ± 1.46, HAS-BLED score: 1.14 ± 0.7). Twenty-one (35.0%) and 23 patients (38.3%) received twice-daily dabigatran 110 or 150 mg; 16 patients (26.6%) received once-daily rivaroxaban (15 mg [n = 5] or 20 mg [n = 11]). Four cases of postprocedural minor bleeding were reported. CONCLUSION This is the first study assessing new oral anticoagulants for periprocedural anticoagulation, specifically in patients undergoing AFL ablation. No major bleeding was reported. Further prospective investigation is warranted.
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Affiliation(s)
- Walid Amara
- Cardiology Department, GHI Le Raincy-Montfermeil, 10 rue du GL Leclerc, 93370 Montfermeil, France
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Kalabalik J, Rattinger GB, Sullivan J, Slugocki M, Carbone A, Rivkin A. Use of Non-Vitamin K Antagonist Oral Anticoagulants in Special Patient Populations with Nonvalvular Atrial Fibrillation: A Review of the Literature and Application to Clinical Practice. Drugs 2015; 75:979-98. [DOI: 10.1007/s40265-015-0405-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Santarpia G, De Rosa S, Polimeni A, Giampà S, Micieli M, Curcio A, Indolfi C. 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. PLoS One 2015; 10:e0126512. [PMID: 25974377 PMCID: PMC4431735 DOI: 10.1371/journal.pone.0126512] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 04/02/2015] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Use 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. OBJECTIVES To perform a meta-analysis of all studies comparing NOACs and vitamin K antagonist oral anticoagulants (VKAs) in patients undergoing RFCA. DATA SOURCES Studies were searched for in PubMed and Google Scholar databases. STUDY ELIGIBILITY CRITERIA Studies 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 METHODS 25 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. RESULTS There 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). LIMITATIONS As with every meta-analysis, no patients-level data were available. CONCLUSIONS AND IMPLICATIONS The 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.
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Affiliation(s)
- Giuseppe Santarpia
- Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia” University, Catanzaro, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia” University, Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia” University, Catanzaro, Italy
| | - Salvatore Giampà
- Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia” University, Catanzaro, Italy
| | - Mariella Micieli
- Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia” University, Catanzaro, Italy
| | - Antonio Curcio
- Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia” University, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia” University, Catanzaro, Italy
- URT-CNR, Department of Medicine, Consiglio Nazionale delle Ricerche, Catanzaro, Italy
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16
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Shi XM, Chen FK, Liang Z, Li J, Lin K, Guo JP, Shan ZL. Is dabigatran efficacy enough to prevent stroke in atrial fibrillation patient with high CHADS2 score during peri-procedural catheter radiofrequency ablation? A case report with literature review. Int J Clin Exp Med 2015; 8:6592-6600. [PMID: 26131290 PMCID: PMC4483948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/05/2015] [Indexed: 06/04/2023]
Abstract
Atrial fibrillation (AF) is a major cause of thromboembolic (TE) events including stroke and transient ischemic attacks, catheter radiofrequency ablation (CA) has been demonstrated to effectively eliminate AF in majority of patients. During the peri-procedural CA of AF, dabigatran, a reversible direct thrombin inhibitor, has been proved as safe and efficacy as warfarin in the prevention of thromboembolic complication. However, for patients with CHADS2 score ≥3, sometimes dabigatran may not be an ideal substitute of warfarin. The current study presents delayed stroke occurred in a middle-aged AF patient with high CHADS2 score who had undergone successful CA of AF being on dabigatran, trans esophageal echocardiogram (TEE) detected a clot in the left atrium appendage (LAA) and magnetic resonance image (MRI) indicated stroke of left basal ganglia, therefore anticoagulant was switched to warfarin with well controlled international normalization ratio (INR) ranging from 2.0-3.0 and the patient eventually recovered without any TE events during the subsequent follow-up.
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Affiliation(s)
- Xiang-Min Shi
- Department of Cardiology, The General Hospital of PLA Beijing 100853, China
| | - Fu-Kun Chen
- Department of Cardiology, The General Hospital of PLA Beijing 100853, China
| | - Zhuo Liang
- Department of Cardiology, The General Hospital of PLA Beijing 100853, China
| | - Jian Li
- Department of Cardiology, The General Hospital of PLA Beijing 100853, China
| | - Kun Lin
- Department of Cardiology, The General Hospital of PLA Beijing 100853, China
| | - Jian-Ping Guo
- Department of Cardiology, The General Hospital of PLA Beijing 100853, China
| | - Zhao-Liang Shan
- Department of Cardiology, The General Hospital of PLA Beijing 100853, China
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17
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Zak M, Castiblanco SA, Garg J, Palaniswamy C, Jacobs LE. Periprocedural Management of New Oral Anticoagulants in Atrial Fibrillation Ablation. J Cardiovasc Pharmacol Ther 2015; 20:457-64. [PMID: 25827857 DOI: 10.1177/1074248415576193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 02/08/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients who undergo catheter ablation for atrial fibrillation (AF) are at increased risk of developing thromboembolic and bleeding complications periprocedurally. Many patients are now on newer oral anticoagulants (NOACs), but data regarding their safety and efficacy during AF ablation are limited. METHODS AND RESULTS This article reviews the literature in PubMed from 1998 to 2014 and includes clinical trials and meta-analysis that analyzed the safety and efficacy of NOACs during AF catheter ablation. Dabigatran seems to be as effective and safe as warfarin, although most data are from single-center studies, with small samples and very low overall bleeding and thromboembolic complications. Periprocedural anticoagulation protocols also vary greatly between studies. Some recent meta-analysis has shown that warfarin could still be a safer and more effective alternative. There are fewer studies with rivaroxaban in AF ablation, and there have been no meta-analysis yet comparing rivaroxaban to warfarin or dabigatran. There seems to be no significant differences in safety or efficacy of rivaroxaban compared to warfarin. Interestingly, there are no available data for apixaban in AF ablation yet. DISCUSSION There are no consensus guidelines regarding the use of NOACs during AF ablation. Dabigatran and rivaroxaban seem as safe and effective as warfarin, although larger studies with standardized protocols are needed, as available studies may be underpowered to detect small differences in bleeding and thromboembolic rates.
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Affiliation(s)
- Martin Zak
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | | | - Jalaj Garg
- Department of Medicine, Division of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Chandrasekar Palaniswamy
- Department of Medicine, Division of Cardiology, Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA
| | - Larry E Jacobs
- Department of Medicine, Division of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
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18
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Maan A, Heist EK, Ruskin JN, Mansour M. Practical issues in the management of novel oral anticoagulants-cardioversion and ablation. J Thorac Dis 2015; 7:115-31. [PMID: 25713727 DOI: 10.3978/j.issn.2072-1439.2014.11.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 10/23/2014] [Indexed: 12/12/2022]
Abstract
Recent research and publication of various landmark trials have led to the approval and subsequent use of novel oral anticoagulants (NOACs) in clinical practice. The use of these newer agents for anticoagulation offers several benefits such as greater specificity, relatively rapid onset and offset of action and a predictable pharmacological profile as compared to warfarin. With the increasing use of these agents, several key issues ranging from appropriate selection to management of complications and considerations for concurrent procedures (cardioversion and catheter ablation) have also emerged. The timing of interruption of anticoagulants prior to catheter ablation and re-initiation after the procedure to minimize the peri-procedural thromboembolism risk without increasing the bleeding risk is of key relevance in electrophysiology practice. The use of NOACs in patients undergoing catheter ablation and cardioversion also requires special considerations based on the pharmacological properties of the individual agent and the presence of comorbidities such as renal and or hepatic impairment. In this review we aim to discuss the practical considerations with the use of NOACs in the setting of cardioversion and catheter ablation based on the currently available data.
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Affiliation(s)
- Abhishek Maan
- Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA 02114, USA
| | - E Kevin Heist
- Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jeremy N Ruskin
- Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Moussa Mansour
- Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA 02114, USA
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19
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Lin T, Bai R, Chen YW, Yu RH, Tang RB, Sang CH, Li SN, Ma CS, Dong JZ. Periprocedural Anticoagulation of Patients Undergoing Pericardiocentesis for Cardiac Tamponade Complicating Catheter Ablation of Atrial Fibrillation. Int Heart J 2015; 56:56-61. [DOI: 10.1536/ihj.14-158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Tao Lin
- Department of Cardiology, Beijing Tian Tan Hospital, Capital Medical University
| | - Rong Bai
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University
| | - Ying-wei Chen
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University
| | - Rong-hui Yu
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University
| | - Ri-bo Tang
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University
| | - Cai-hua Sang
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University
| | - Song-nan Li
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University
| | - Chang-sheng Ma
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University
| | - Jian-zeng Dong
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University
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20
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Armbruster HL, Lindsley JP, Moranville MP, Habibi M, Khurram IM, Spragg DD, Berger RD, Calkins H, Marine JE. Safety of Novel Oral Anticoagulants Compared With Uninterrupted Warfarin for Catheter Ablation of Atrial Fibrillation. Ann Pharmacother 2014; 49:278-84. [DOI: 10.1177/1060028014563950] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The novel oral anticoagulants (NOACs) are used for stroke prevention in atrial fibrillation (AF), but their safety and efficacy in the periablation period are not well established. Additionally, no standard procedure for managing periprocedural and intraprocedural anticoagulation has been established. Objective: To evaluate the frequency of hemorrhagic and thrombotic events as well as periprocedural management strategies of NOACs compared with warfarin as anticoagulation therapy for AF ablation. Methods: This was a retrospective cohort study from a prospective AF ablation registry maintained at a large, academic medical center. Results: A total of 374 cases (173 warfarin, 123 dabigatran, 61 rivaroxaban, and 17 apixaban) were included in the analysis. The overall hemorrhagic/thrombotic event rate was 14.2 % (major hemorrhage 2.7%, minor hemorrhage 11.2%, thrombotic stroke 0.5%). The frequency of minor hemorrhage was significantly higher with warfarin compared with dabigatran (15% vs 5.7%, P = 0.012). The average heparin dose required to reach the goal activated clotting time (ACT) was 5600 units for warfarin, 12 900 units for dabigatran ( P < 0.001), 15 100 units for rivaroxaban ( P < 0.001), and 14 700 units for apixaban ( P < 0.001). The average time in minutes to reach the goal ACT was significantly longer, compared with warfarin, for dabigatran (57 vs 28, P < 0.001), rivaroxaban (63 vs 28, P < 0.001), and apixaban (72 vs 28, P < 0.001). Conclusions: Compared with warfarin, periprocedural anticoagulation with dabigatran resulted in fewer minor hemorrhages and total adverse events after AF ablation. Patients anticoagulated with NOACs required larger doses of heparin and took longer to reach the goal ACT compared with patients anticoagulated with warfarin.
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Affiliation(s)
| | | | | | | | | | - David D. Spragg
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Hugh Calkins
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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GARTON ALEXB, DUDZINSKI JOHN, KOWEY PETERR. Oral Anticoagulant Use Around the Time of Atrial Fibrillation Ablation: A Review of the Current Evidence of Individual Oral Anticoagulant Use for Periprocedural Atrial Fibrillation Ablation Thromboembolic Prophylaxis. J Cardiovasc Electrophysiol 2014; 25:1411-8. [DOI: 10.1111/jce.12546] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/14/2014] [Accepted: 08/27/2014] [Indexed: 11/29/2022]
Affiliation(s)
- ALEX B. GARTON
- Division of Cardiovascular Disease; Lankenau Medical Center; Wynnewood Pennsylvania USA
| | - JOHN DUDZINSKI
- Department of Internal Medicine; Lankenau Medical Center; Wynnewood Pennsylvania USA
| | - PETER R. KOWEY
- Division of Cardiovascular Disease; Lankenau Medical Center; Wynnewood Pennsylvania USA
- Department of Internal Medicine; Lankenau Medical Center; Wynnewood Pennsylvania USA
- Jefferson Medical College; Philadelphia Pennsylvania USA
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22
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Di Biase L. Safety and efficacy of novel oral anticoagulants in the setting of atrial fibrillation ablation: Is it time to celebrate the "funeral" of warfarin? J Interv Card Electrophysiol 2014; 41:103-5. [PMID: 25227869 DOI: 10.1007/s10840-014-9944-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 08/06/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Luigi Di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, New York, USA,
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23
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Kitslaar DB, Wysokinski WE, McBane RD. The Role of Novel Anticoagulants in the Management of Venous Thromboembolic Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:326. [DOI: 10.1007/s11936-014-0326-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Sardar P, Nairooz R, Chatterjee S, Wetterslev J, Ghosh J, Aronow WS. Meta-analysis of risk of stroke or transient ischemic attack with dabigatran for atrial fibrillation ablation. Am J Cardiol 2014; 113:1173-7. [PMID: 24513472 DOI: 10.1016/j.amjcard.2013.12.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 12/16/2013] [Accepted: 12/16/2013] [Indexed: 11/17/2022]
Abstract
Dabigatran is a novel oral anticoagulant and may be useful during atrial fibrillation (AF) ablation for prevention of thromboembolic events. However, the benefits and adverse effects of periprocedural dabigatran therapy have not been thoroughly evaluated. A meta-analysis was performed to evaluate the efficacy and safety of dabigatran for anticoagulation in AF ablation. PubMed, The Cochrane Library, EMBASE, Web of Science, and CINAHL databases were searched from January 01, 2001 through July 30, 2013. Two reviewers reviewed the studies for inclusion and extracted data from studies comparing dabigatran with warfarin for AF ablation. A total of 5,513 patients undergoing catheter ablation were included in 17 observational studies and 1 randomized trial. Fourteen events of stroke or transient ischemic attacks were reported in the dabigatran group and 4 in the warfarin group (Peto's odds ratio 3.94, 95% confidence interval [CI] 1.54 to 10.08, number needed to harm=284 patients). The risk of all thromboembolic complications was also higher in the dabigatran group compared with the warfarin group (Peto's odds ratio 2.81, 95% CI 1.23 to 6.45). No major differences were observed for the risk of major bleeding (odds ratio 0.99, 95% CI 0.55 to 1.78), pericardial tamponade, and groin hematoma. A lower risk of minor bleeding was observed with dabigatran (odds ratio 0.60, 95% CI 0.41 to 0.87). In conclusion, periprocedural use of dabigatran for AF ablation was related to a higher risk of thromboembolic complications including stroke and transient ischemic attack.
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Affiliation(s)
- Partha Sardar
- Department of Medicine, New York Medical College, New York, New York.
| | - Ramez Nairooz
- Department of Medicine, New York Medical College, New York, New York
| | - Saurav Chatterjee
- Department of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Center for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joydeep Ghosh
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Wilbert S Aronow
- Cardiology Division, New York Medical College, Valhalla, New York
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25
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DeSimone CV, Madhavan M, Ebrille E, Rabinstein AA, Friedman PA, Asirvatham SJ. Atrial Fibrillation and Stroke: Increasing Stroke Risk with Intervention. Card Electrophysiol Clin 2014; 6:87-94. [PMID: 27063823 DOI: 10.1016/j.ccep.2013.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article focuses on the important newly recognized appreciation for the paradoxic increase in stroke and transient ischemic attack as a result of intervention meant to treat atrial fibrillation (AF) with the hope of decreasing stroke risk in the long term. The impact of silent cerebral lesions has recently been identified as a potentially major limitation, and the risks with AF ablation, as well as the present understanding of how risk can be minimized, are explained. This article provides a platform for newer study, changes in the way procedures are done, and possibly vascular-based stroke-reduction strategies.
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Affiliation(s)
- Christopher V DeSimone
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Malini Madhavan
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Elisa Ebrille
- Department of Cardiology, University of Turin, S. Giovanni Battista, Corso Bramante, Turin, Italy
| | - Alejandro A Rabinstein
- Department of Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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26
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DeSimone CV, Madhavan E, Ebrille S, Rabinstein AA, Friedman PA, Asirvatham SJ. Atrial Fibrillation and Stroke - Increasing Stroke Risk With Intervention. J Atr Fibrillation 2013; 6:966. [PMID: 28496915 PMCID: PMC4829953 DOI: 10.4022/jafib.966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 12/18/2013] [Accepted: 12/18/2013] [Indexed: 06/07/2023]
Abstract
In this review, we focus on the important newly recognized appreciation for the paradoxical increase in stroke and TIA as a result of intervention meant to treat atrial fibrillation (AF) with the hope of decreasing stroke risk in the long term. The impact of silent cerebral lesions recently appreciated as a potentially major limitation and risk with AF ablation is explained. We categorize our present understanding of how we can minimize risk and provide a platform for what will undoubtedly be newer study, changes in the way procedures are done today, and possibly vascular-based stroke-reduction strategies.
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Affiliation(s)
| | - Elisa Madhavan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | - Paul A Friedman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
- Department of Pediatrics and Adolescent Medicine Mayo Clinic, Rochester, MN
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27
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Safety and efficacy of dabigatran compared with warfarin for patients undergoing radiofrequency catheter ablation of atrial fibrillation: a meta-analysis. Can J Cardiol 2013; 29:1203-10. [PMID: 23993352 DOI: 10.1016/j.cjca.2013.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/09/2013] [Accepted: 07/10/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The safety and efficacy of dabigatran in the periprocedural period for patients undergoing atrial fibrillation ablation is not well established. We conducted a meta-analysis of the periprocedural use of dabigatran vs warfarin (with or without heparin bridging). METHODS A literature search was performed using multiple databases. Outcomes were (1) major bleeding; (2) minor bleeding; and (3) thromboembolic events. Odds ratios (ORs) were reported for dichotomous variables. RESULTS Eleven controlled studies (9 cohorts, 1 randomized controlled trial and 1 case-control study; 3841 patients) were identified. Dabigatran was used in 1463 patients, uninterrupted in 223 and held up to 36 hours in the remainder. No significant differences were noted in major bleeding rates between dabigatran and warfarin groups (1.9% vs. 1.6%; OR, 1.04 [95% confidence interval (CI), 0.51-2.13]; P = 0.92). Cardiac tamponade was observed in 1.4% in dabigatran vs 1.1% in warfarin groups (OR, 1.1; 95% CI, 0.55-2.11; P = 0.82). Similar rates for dabigatran vs. warfarin were reported for minor bleeding (3.8% vs. 4.5%; OR, 0.85; 95% CI, 0.58-1.25; P = 0.40), hematoma (2% vs. 2.7%; OR, 0.67; 95% CI, 0.41-1.08; P = 0.1), and thromboembolic events (0.6% vs. 0.1%; OR, 2.51; 95% CI, 0.78-8.11; P = 0.12). CONCLUSIONS This meta-analysis suggests that dabigatran and warfarin have similar safety and efficacy overall for periprocedural anticoagulation in patients undergoing radiofrequency atrial fibrillation ablation. Signals were seen favouring dabigatran (for hematomas) and warfarin (for thromboembolic events), but neither was statistically significant because of low event rates. More high-quality data are required to definitively compare the 2 strategies.
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28
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Bin Abdulhak AA, Khan AR, Tleyjeh IM, Spertus JA, Sanders SU, Steigerwalt KE, Garbati MA, Bahmaid RA, Wimmer AP. Safety and efficacy of interrupted dabigatran for peri-procedural anticoagulation in catheter ablation of atrial fibrillation: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2013; 15:1412-20. [DOI: 10.1093/europace/eut239] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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29
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Safety and efficacy of dabigatran etexilate during catheter ablation of atrial fibrillation: a meta-analysis of the literature. ACTA ACUST UNITED AC 2013; 15:1407-11. [DOI: 10.1093/europace/eut241] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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30
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Noheria A, Asirvatham SJ. Periprocedural dabigatran anticoagulation for atrial fibrillation ablation: do we have enough information to make a rational decision. J Interv Card Electrophysiol 2013; 37:209-11. [PMID: 23892446 DOI: 10.1007/s10840-013-9821-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 06/27/2013] [Indexed: 11/30/2022]
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