Abstract
Adequate anticoagulation during catheter ablation (CA) for atrial fibrillation (AF) is crucial for the prevention of both thromboembolic events and life-threatening bleeding. The purpose of this updated meta-analysis is to compare the safety and efficacy of uninterrupted and minimally interrupted periprocedural direct oral anticoagulant (DOAC) protocols and uninterrupted vitamin K antagonist (VKA) therapy in patients undergoing CA for AF based on the latest evidence. Randomized controlled trials, prospective observational studies, and retrospective registries comparing DOACs to VKAs were identified in multiple databases (Embase, MEDLINE via PubMed, CENTRAL, and Scopus). The primary outcomes were stroke or transient ischemic attack (TIA), major bleeding, and net clinical benefit. Forty-two studies with a total of 22,715 patients were included in the final analysis. The occurrence of major bleeding was significantly lower in patients assigned to uninterrupted DOAC treatment compared to VKAs (pooled odds ratio (POR): 0.71, confidence interval (CI): 0.51–0.99). The pooled analysis of both uninterrupted and minimally interrupted DOAC groups also showed significant reduction in major bleeding events (POR: 0.70, CI: 0.53–0.93). The incidence of thromboembolic events was low, with no significant difference between groups. This updated meta-analysis showed that DOAC therapy is as effective as VKA in preventing stroke and TIA. Minimally interrupted DOAC therapy is a non-inferior periprocedural anticoagulation strategy; however, uninterrupted DOAC therapy showed superiority compared to VKA with regard to major, life-threatening bleeding. Based on our in-depth analysis, we conclude that both DOAC strategies are equally safe and preferable alternatives to VKAs in patients undergoing CA for AF.
Highlights
Atrial fibrillation (AF) is the most common sustained arrhythmia in adults, and its prevalence is expected to increase notably during the three decades [1]
Oral anticoagulation significantly reduces the risk of ischemic stroke and mortality in AF patients [3]: in a well-managed anticoagulated AF population, the annual incidence and mortality of stroke are around 1.5% and 3%, respectively [4,5,6,7]
The search was structured using the PICO format, where the target population was patients after catheter ablation (CA) for AF, the periprocedural direct oral anticoagulant (DOAC) anticoagulation strategy was compared to vitamin K antagonist (VKA) treatment, and the outcomes were thromboembolic and bleeding events
Summary
Atrial fibrillation (AF) is the most common sustained arrhythmia in adults, and its prevalence is expected to increase notably during the three decades [1]. Oral anticoagulation significantly reduces the risk of ischemic stroke and mortality in AF patients [3]: in a well-managed anticoagulated AF population, the annual incidence and mortality of stroke are around 1.5% and 3%, respectively [4,5,6,7]. Therapeutic strategies for rate or rhythm control have substantially improved over the past few decades, with catheter ablation (CA) gaining increasing importance. The 2020 guidelines of the European Society of Cardiology (ESC) recommend CA for pulmonary vein isolation (PVI) for rhythm control after failure of drug therapy to improve symptoms of AF recurrences in patients with paroxysmal or persistent AF without major risk factors for AF recurrence (Class I A) [10]
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