title: Effect of pre-procedural interrupted apixaban on heparin anticoagulation during catheter ablation for atrial fibrillation: a prospective observational study.
abstract: OBJECTIVE
  Effective intraprocedural anticoagulation is considered essential to minimize the risk of thromboembolism in catheter ablation (CA) of atrial fibrillation (AF). The effect of interrupted apixaban on intraprocedural heparin dosing requirements and levels of achieved anticoagulation with heparin has not been well studied. The purpose of the present study was to compare heparin administration and activated clotted times (ACTs) for patients undergoing CA for AF treated with interrupted apixaban before the procedure with patients on uninterrupted warfarin.
  
  
  METHODS
  Consecutive patients undergoing CA for AF treated with interrupted apixaban or uninterrupted warfarin were prospectively enrolled. Heparin administration determined by a standard protocol and normalized to patient weight and procedure duration, as well as rapidity, and degree of anticoagulation with heparin (as measured by mean ACT, peak ACT, time to ACT ≥300 s, and time to ACT ≥350 s) were compared between the groups.
  
  
  RESULTS
  Forty-eight patients were enrolled (25 apixaban and 23 warfarin). Heparin administered by bolus (51.3 ± 21.5 vs 27.8 ± 9.6 units/kg/h; p < 0.001) and mean heparin drip rate (25.3 ± 3.6 vs 20.7 ± 2.4 units/kg/h; p < 0.001) were significantly higher in the apixaban group compared to the warfarin group. Despite greater heparin administration, apixaban patients achieved a significantly lower mean ACT (332.3 ± 17.0 vs 384.5 ± 53.9; p < 0.001) and peak ACT (369.5 ± 22.6 vs 432.3 ± 75.8, p < 0.001) compared to the warfarin group. The time to ACT ≥350 s (66.7 ± 35.8 vs 26.9 ± 34.0; p < 0.001) was significantly longer for apixaban-treated patients. Outcome differences persisted after analysis using linear models and Cox proportional hazard regression with adjustment for propensity scores.
  
  
  CONCLUSIONS
  A standard intraprocedural heparin protocol results in delayed and lower levels of anticoagulation as measured by the ACT for interrupted apixaban-treated patients in comparison to those on uninterrupted warfarin during CA of AF.
authors: Division of Cardiovascular Disease, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors: Aref A
authors: AA
authors: Bin Abdulhak
authors: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, 4330 Wornall Road, Suite 2000, Kansas City, MO, 64111, USA.
authors: Kevin F
authors: KF
authors: Kennedy
authors: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, 4330 Wornall Road, Suite 2000, Kansas City, MO, 64111, USA.|Department of Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.
authors: Sanjaya
authors: S
authors: Gupta
authors: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, 4330 Wornall Road, Suite 2000, Kansas City, MO, 64111, USA.|Department of Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.
authors: Michael
authors: M
authors: Giocondo
authors: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, 4330 Wornall Road, Suite 2000, Kansas City, MO, 64111, USA.|Department of Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.
authors: Brian
authors: B
authors: Ramza
authors: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, 4330 Wornall Road, Suite 2000, Kansas City, MO, 64111, USA. awimmer@saint-lukes.org.|Department of Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA. awimmer@saint-lukes.org.
authors: Alan P
authors: AP
authors: Wimmer
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects* / Q000379:methods; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D065427:Factor Xa Inhibitors / Q000008:administration & dosage; D005260:Female; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D007275:Injections, Intravenous; D007430:Intraoperative Care / Q000379:methods; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011292:Premedication / Q000379:methods*; D011300:Preoperative Care / Q000379:methods; D011446:Prospective Studies; D011720:Pyrazoles / Q000008:administration & dosage*; D011728:Pyridones / Q000008:administration & dosage*; D013923:Thromboembolism / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D065427:Factor Xa Inhibitors; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D006493:Heparin
keywords: Anticoagulation; Apixaban; Atrial fibrillation; Catheter ablation; Warfarin