Oral anticoagulation is frequently discontinued after ablation of paroxysmal atrial fibrillation despite previous stroke: data from the German Ablation Registry
- 437 Downloads
Atrial fibrillation (AF) is the most common cause of ischemic stroke. Recent data suggest that AF patients after successful ablation have the same risk for thromboembolic events (TE) as patients without AF. Despite current guideline recommendations it is still under debate if oral anticoagulation (OAC) can be safely discontinued after ablation. We analyzed follow-up (FU) after ablation of paroxysmal AF (PAF) in a high- (previous stroke; group 1) and a low-risk group (no previous stroke; group 2) based on data from the German Ablation Registry to reveal real-life prescription behavior.
Overall 29 centers in Germany participated by performing AF-ablation. Between April 2008 and April 2011, 83 patients in group 1 and 377 patients in group 2 with a first ablation of PAF were included in the registry.
Mean CHA2DS2-VASc-Score was 4.2 ± 1.4 (group 1) vs. 1.6 ± 1.2 (group 2) (p < 0.0001). No peri-interventional TE was observed. Arrhythmia recurrence was seen in 47.4 vs. 48.4 % (p = 0.79) during a median FU of 489 (453–782) days, resulting in a repeat procedure in 20.0 vs. 20.7 % (p = 0.88), respectively. OAC was discontinued in 38.6 % in group 1 vs. 66.3 % in group 2 (p < 0.0001) during FU. TE during FU occurred more often in group 1 than in group 2 (4.3 vs. 0.3 %, p < 0.05).
Even in patients with previous stroke, OAC was frequently discontinued during FU after PAF ablation in this observational study. However, TE occurred significantly more frequent in these high-risk patients. These data argue against OAC discontinuation after ablation in patients with previous stroke.
KeywordsAtrial fibrillation Pulmonary vein isolation Thromboembolic complications Anticoagulation Stroke
Complex fractionated atrial electrogram
Left ventricular ejection fraction
Major adverse cardiac and cerebrovascular events: death, myocardial infarction, stroke
Paroxysmal atrial fibrillation
Pulmonary vein isolation
Severe non-fatal adverse events: myocardial infarction, stroke, major bleeding
Transient ischemic attack
This project was supported by an unrestricted grant from the Institute for Research in Myocardial Infarction (Ludwigshafen, Germany).
Conflict of interest
All authors declare no conflicts of interest regarding this manuscript.
- 2.Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De CR, De SJ, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH (2010) Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace 12:1360–1420CrossRefPubMedGoogle Scholar
- 5.Oral H, Chugh A, Ozaydin M, Good E, Fortino J, Sankaran S, Reich S, Igic P, Elmouchi D, Tschopp D, Wimmer A, Dey S, Crawford T, Pelosi F Jr, Jongnarangsin K, Bogun F, Morady F (2006) Risk of thromboembolic events after percutaneous left atrial radiofrequency ablation of atrial fibrillation. Circulation 114:759–765CrossRefPubMedGoogle Scholar
- 6.Hunter RJ, McCready J, Diab I, Page SP, Finlay M, Richmond L, French A, Earley MJ, Sporton S, Jones M, Joseph JP, Bashir Y, Betts TR, Thomas G, Staniforth A, Lee G, Kistler P, Rajappan K, Chow A, Schilling RJ (2012) Maintenance of sinus rhythm with an ablation strategy in patients with atrial fibrillation is associated with a lower risk of stroke and death. Heart 98:48–53CrossRefPubMedGoogle Scholar
- 7.Themistoclakis S, Corrado A, Marchlinski FE, Jais P, Zado E, Rossillo A, Di BL, Schweikert RA, Saliba WI, Horton R, Mohanty P, Patel D, Burkhardt DJ, Wazni OM, Bonso A, Callans DJ, Haissaguerre M, Raviele A, Natale A (2010) The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation. J Am Coll Cardiol 55:735–743CrossRefPubMedGoogle Scholar
- 8.Guiot A, Jongnarangsin K, Chugh A, Suwanagool A, Latchamsetty R, Myles JD, Jiang Q, Crawford T, Good E, Pelosi F Jr, Bogun F, Morady F, Oral H (2012) Anticoagulant therapy and risk of cerebrovascular events after catheter ablation of atrial fibrillation in the elderly. J Cardiovasc Electrophysiol 23:36–43CrossRefPubMedGoogle Scholar
- 9.Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D (2012) 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm 9:632–696CrossRefPubMedGoogle Scholar
- 10.Ouyang F, Bansch D, Ernst S, Schaumann A, Hachiya H, Chen M, Chun J, Falk P, Khanedani A, Antz M, Kuck KH (2004) Complete isolation of left atrium surrounding the pulmonary veins: new insights from the double-Lasso technique in paroxysmal atrial fibrillation. Circulation 110:2090–2096CrossRefPubMedGoogle Scholar
- 11.Kornej J, Hindricks G, Kosiuk J, Arya A, Sommer P, Husser D, Rolf S, Richter S, Piorkowski C, Gaspar T, Lip GY, Bollmann A (2013) Renal dysfunction, stroke risk scores (CHADS2, CHA2DS2-VASc, and R2CHADS2), and the risk of thromboembolic events after catheter ablation of atrial fibrillation: the Leipzig Heart Center AF Ablation Registry. Circ Arrhythm Electrophysiol 6:868–874CrossRefPubMedGoogle Scholar
- 12.Mardigyan V, Verma A, Birnie D, Guerra P, Redfearn D, Becker G, Champagne J, Sapp J, Gula L, Parkash R, Macle L, Crystal E, O’Hara G, Khaykin Y, Sturmer M, Veenhuyzen GD, Greiss I, Sarrazin JF, Mangat I, Novak P, Skanes A, Roux JF, Chauhan V, Hadjis T, Morillo CA, Essebag V (2013) Anticoagulation management pre- and post atrial fibrillation ablation: a survey of canadian centres. Can J Cardiol 29:219–223CrossRefPubMedGoogle Scholar
- 15.Chao TF, Ambrose K, Tsao HM, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Suenari K, Li CH, Hartono B, Chang HY, Wu TJ, Chen SA (2012) Relationship between the CHADS(2) score and risk of very late recurrences after catheter ablation of paroxysmal atrial fibrillation. Heart Rhythm 9:1185–1191CrossRefPubMedGoogle Scholar
- 16.Chao TF, Lin YJ, Tsao HM, Tsai CF, Lin WS, Chang SL, Lo LW, Hu YF, Tuan TC, Suenari K, Li CH, Hartono B, Chang HY, Ambrose K, Wu TJ, Chen SA (2011) CHADS(2) and CHA(2)DS(2)-VASc scores in the prediction of clinical outcomes in patients with atrial fibrillation after catheter ablation. J Am Coll Cardiol 58:2380–2385CrossRefPubMedGoogle Scholar
- 17.Bunch TJ, Crandall BG, Weiss JP, May HT, Bair TL, Osborn JS, Anderson JL, Muhlestein JB, Horne BD, Lappe DL, Day JD (2011) Patients treated with catheter ablation for atrial fibrillation have long-term rates of death, stroke, and dementia similar to patients without atrial fibrillation. J Cardiovasc Electrophysiol 22:839–845CrossRefPubMedGoogle Scholar
- 18.Chao TF, Cheng CC, Lin WS, Tsao HM, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Suenari K, Li CH, Liu SH, Hartono B, Wu TJ, Chen SA (2011) Associations among the CHADS(2) score, atrial substrate properties, and outcome of catheter ablation in patients with paroxysmal atrial fibrillation. Heart Rhythm 8:1155–1159CrossRefPubMedGoogle Scholar