Safety and efficacy of nonvitamin K antagonist oral anticoagulants during catheter ablation of atrial fibrillation: A systematic review and meta-analysis

Zhen Ge; Michela Faggioni; Usman Baber; Samantha Sartori; Sabato Sorrentino; Serdar Farhan; Jaya Chandrasekhar; Birgit Vogel; Abdul Qadeer; Jonathan Halperin; Vivek Reddy; Srinivas Dukkipati; George Dangas; Roxana Mehran

doi:10.1111/1755-5922.12457

Safety and efficacy of nonvitamin K antagonist oral anticoagulants during catheter ablation of atrial fibrillation: A systematic review and meta-analysis

Cardiovasc Ther. 2018 Oct;36(5):e12457. doi: 10.1111/1755-5922.12457. Epub 2018 Jul 30.

Authors

Affiliations

¹ Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York.
² Division of cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.

PMID: 29971964
DOI: 10.1111/1755-5922.12457

Abstract

Aims: Catheter ablation for atrial fibrillation (AF) is associated with a transitory increase in the risk of both thromboembolic and bleeding events. Evidence on the use of nonvitamin K antagonist oral anticoagulants (NOACs) in patients undergoing AF ablation mostly comes from small observational studies, underpowered to detect differences in clinical outcomes between NOACs and vitamin K antagonists (VKAs) treated patients. This updated meta-analysis aimed to determine the safety and efficacy of periprocedural anticoagulation with NOACs compared with VKAs in AF patients undergoing catheter ablation.

Methods: We searched MEDLINE, Cochrane library, and web sources for randomized and observational studies comparing periprocedural treatment with NOACs and VKAs in patients undergoing AF ablation. The primary safety endpoint was major bleeding events, and the primary efficacy endpoint was thromboembolic events (a composite of systemic thromboembolism, transient ischemic attack, and stroke).

Results: A total of 29 studies with 12 644 patients were included in the meta-analysis. Overall, patients on NOACs had a significantly lower risk of major bleeding compared to VKAs either in observational studies (Peto OR 0.68; 95% CI: 0.48-0.95; P = 0.022; I² = 20%) or in RCTs (Peto OR 0.30; 95% CI: 0.14-0.62; P = 0.001; I² = 28%). Uninterrupted NOACs reduced the risk of major bleeding when compared to uninterrupted VKAs (Peto OR 0.66; 95% CI: 0.45-0.96; P = 0.028; I² = 1%), similarly, interrupted NOACs lowered the risk of major bleeding compared to interrupted VKAs (Peto OR 0.29; 95% CI: 0.13-0.66; P = 0.003; I² = 0%; P_interaction = 0.076). The rate of thromboembolic complications was very low and did not significantly differ between the study groups either in observational studies (Peto OR 0.91; 95% CI: 0.49-1.67; P = 0.755; I² = 0%) or in RCTs (Peto OR 0.14; 95% CI: 0.01-1.30; P = 0.083; I² = 0%).

Conclusions: Use of NOACs compared to VKAs significantly reduced the risk of bleeding in patients with AF ablation. Similarly, the risk of bleeding was lower with uninterrupted NOACs than with uninterrupted VKAs, and with interrupted NOACs than with interrupted VKAs. The rate of thromboembolic complications was extremely low in both study groups without any differences.

Keywords: atrial fibrillation; catheter ablation; nonvitamin K antagonist oral anticoagulants; vitamin K antagonists.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Administration, Oral
Anticoagulants / administration & dosage*
Anticoagulants / adverse effects
Atrial Fibrillation / diagnosis
Atrial Fibrillation / physiopathology
Atrial Fibrillation / therapy*
Blood Loss, Surgical / prevention & control
Catheter Ablation* / adverse effects
Drug Administration Schedule
Humans
Patient Safety
Postoperative Hemorrhage / chemically induced
Risk Assessment
Risk Factors
Treatment Outcome
Venous Thromboembolism / prevention & control
Vitamin K / antagonists & inhibitors

Substances

Anticoagulants
Vitamin K