Abstract
BackgroundUse 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.ObjectivesTo perform a meta-analysis of all studies comparing NOACs and vitamin K antagonist oral anticoagulants (VKAs) in patients undergoing RFCA.Data SourcesStudies were searched for in PubMed and Google Scholar databases.Study Eligibility CriteriaStudies 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 Methods25 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.ResultsThere 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).LimitationsAs with every meta-analysis, no patients-level data were available.Conclusions and ImplicationsThe 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.
Highlights
Atrial fibrillation (AF) is the most common arrhythmia, its prevalence in the developed World is approximately 1.5–2% of the general population [1]
The use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients undergoing RFCA is safe, given the lower incidence of bleedings observed with NOACs
Periprocedural interruption of vitamin K antagonist oral anticoagulants (VKAs) and bridging with heparin is associated with a higher bleeding rate with no significant benefit on onset of thromboembolic events
Summary
Atrial fibrillation (AF) is the most common arrhythmia, its prevalence in the developed World is approximately 1.5–2% of the general population [1]. Vitamin K antagonists, the only available drugs for long-term anticoagulation over the last 60 years, have some flaws: a) several days are needed to reach the full therapeutic effect; b) complex overlap with parenteral anticoagulants; c) narrow therapeutic window, which potentially exposes to the dreadful risk of bleeding; d) significant interaction with several drugs and food, making continuous monitoring of the therapeutic effect mandatory; e) common genetic variations of its metabolism. For these reasons, up to 65% of all patients at risk were not taking oral anticoagulants (OACs), while the international normalized ratio (INR) was out of range in a further 19% of patients [4]. Efficacy and safety of NOACs in patients undergoing catheter ablation (RFCA) of AF has not been well established yet
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