Author + information
- Received June 3, 2019
- Revision received July 23, 2019
- Accepted August 8, 2019
- Published online December 16, 2019.
- Jorge Romero, MDa,∗,
- Roberto C. Cerrud-Rodriguez, MDa,∗,
- Isabella Alviz, MDa,
- Juan Carlos Diaz, MDa,
- Daniel Rodriguez, MDa,
- Samiullah Arshad, MDa,
- Luis Cerna, MDa,
- Jose Taveras, MDa,
- Vito Grupposo, RTa,
- Andrea Natale, MDb,
- Mario Garcia, MDa and
- Luigi Di Biase, MD, PhDa,∗ ()
- aMontefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
- bTexas Cardiac Arrhythmia Institute at St. David’s Medical Center, Austin, Texas
- ↵∗Address for correspondence:
Dr. Luigi Di Biase, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, New York 10467.
Objectives This study assessed the incremental benefit of uninterrupted direct oral anticoagulants (DOACs) versus uninterrupted vitamin K antagonists (VKAs) for catheter ablation (CA) of nonvalvular atrial fibrillation (NVAF) on 3 primary outcomes: major bleeding events (MBEs), minor bleeding events, and thromboembolic events (TEs). The secondary outcome was post-procedural silent cerebral infarction (SCI) as detected by brain cardiac magnetic resonance.
Background As a class, evidence of the benefits of DOACs versus VKAs during CA of AF is scant.
Methods A systematic review of Medline, Cochrane, and Embase was done to find all randomized controlled trials in which uninterrupted DOACs were compared against uninterrupted VKAs for CA of NVAF. A fixed-effect model was used, except when I2 was ≥25, in which case, a random effects model was used.
Results The benefit of uninterrupted DOACs over VKAs was analyzed from 6 randomized control trials that enrolled a total of 2,256 patients (male: 72.7%) with NVAF, finding significant benefit in MBEs (relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.20 to 0.99; p = 0.05). No significant differences were found in minor bleeding events (RR: 1.12; 95% CI: 0.87 to 1.43; p = 0.39), TEs (RR: 0.75; 95% CI: 0.26 to 2.14; p = 0.59), or post-procedural SCI (RR: 1.09; 95% CI: 0.80 to 1.49; p = 0.58).
Conclusions An uninterrupted DOACs strategy for CA of AF appears to be safer than uninterrupted VKAs with a decreased rate of major bleeding events. There are no significant differences among the other outcomes. DOACs should be offered as a first-line therapy to patients undergoing CA of AF, due to their lower risk of major bleeding events, ease of use, and fewer interactions.
- atrial fibrillation
- catheter ablation
- direct oral anticoagulants
- randomized controlled trials
- vitamin K antagonists
↵∗ Drs. Romero and Cerrud-Rodriguez contributed equally to this work and are joint first authors.
Dr. Di Biase has served as a consultant for Biosense Webster, Boston Scientific, Stereotaxis, and St. Jude Medical; and has received speaker honoraria/travel support from Biosense Webster, St. Jude Medical, Boston Scientific, Medtronic, Bristol-Myers Squibb, Pfizer, and Biotronik. Dr. Natale has served as a consultant for Baylis Medical, Boston Scientific, Biosense Webster, Bristol-Myers Squibb, St. Jude Medical, Biotronik, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received June 3, 2019.
- Revision received July 23, 2019.
- Accepted August 8, 2019.
- 2019 American College of Cardiology Foundation
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