Should We Maintain Anticoagulation after Successful Radiofrequency Catheter Ablation of Atrial Fibrillation? The Need for a Randomized Study.

Giuseppe Santarpia,Salvatore De Rosa,Ciro Indolfi,Jolanda Sabatino,Antonio Curcio

doi:10.3389/fcvm.2017.00085

Abstract

Atrial fibrillation (AF) is associated with a high risk of thromboembolic stroke and oral anticoagulation therapy (OAT) is able to reduce the rate of ischemic events. Nevertheless, the actual benefit of prolonged OAT after successful radiofrequency catheter ablation (RFCA) is not clear yet. Scientific investigations were assumed suitable if they assessed the clinical significance of the use of anticoagulation versus no anticoagulation in AF patients undergoing successful RFCA. The odds ratio (OR) with 95% confidence interval (CI) was used as the study summary measure. At meta-analysis, the rate of total thromboembolic events was not significantly different between the groups (OR 1.83, 95% CI 0.69-4.88; p = 0.221), while a lower incidence of total bleeding events in patients not treated with OAT was found (OR 6.5, 95% CI 1.93-21.86; p = 0.002). This meta-analysis raises doubts about the net clinical benefit (NCB) of a long-term prophylactic OAT in patients with AF underwent to successful RFCA. In fact, despite similar rate of thromboembolic events, the apparent increase in bleeding risk suggests caution in prolonging OAT after RFCA. However, the lack of prospective randomized studies does not allow a comprehensive appraisal of this issue. Thus, we propose the design of a novel prospective randomized trial to evaluate the NCB of prolonged OAT after successful RFCA of AF.

Highlights

Atrial fibrillation (AF) is associated with a high risk of thromboembolic stroke and oral anticoagulation therapy (OAT) is able to reduce the rate of ischemic events
Baseline thromboembolic and bleeding risk profiles were not balanced between the study arms for most of the studies included in the analysis and heterogeneously reported
Longterm anticoagulation was reintroduced after the radiofrequency catheter ablation (RFCA) and kept for 3–12 months; it was represented by adjusted-dose warfarin in eight studies and either by warfarin or by non-vitamin K antagonist oral anticoagulants (NOACs) in the remaining study [22]

Summary

Introduction

Atrial fibrillation (AF) is associated with a high risk of thromboembolic stroke and oral anticoagulation therapy (OAT) is able to reduce the rate of ischemic events. Anticoagulation after RFCA of AF able to achieve a 60% relative risk reduction of ischemic stroke, compared to placebo [3] For this reason, clinical guidelines for the management of AF suggest the use of OAT in all AF patients with high thromboembolic risk, with the use of percutaneous left atrial appendage occlusion being recommended in patients with clear contra-indications for OAT [4,5,6]. The lack of randomized trials testing long-term safety and efficacy of OAT in this specific population makes clinicians unsure on their actual usefulness in AF patients after successful RFCA. We performed a critical revision of available clinical data on the advantage of anticoagulation versus no anticoagulation in AF patients after successful RFCA, adopting a meta-analytic approach, to integrate the conclusions of all eligible academic works with the following definite objectives: [1] evaluate safety and efficacy of anticoagulation versus non-use of anticoagulation in AF patients undergoing successful RFCA and [2] highlight the current knowledge gaps and design a randomized trial to test safety and efficacy of anticoagulation in AF patients undergoing successful RFCA, without selection bias

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