Efficacy and Safety of Novel Oral Anticoagulants for Atrial Fibrillation Ablation: An Updated Meta-Analysis.
BACKGROUND
Novel oral anticoagulants (NOACs) have been approved for prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). A large number of patients are on NOACs when they present for AF ablation. We intended to evaluate the safety and efficacy of NOACs for AF ablation during the periprocedural period by performing a meta-analysis of trials comparing NOACs with warfarin.


METHODS
Studies comparing NOACs (dabigatran and rivaroxaban) with warfarin as periprocedural anticoagulants for AF ablation were identified using an electronic search. Primary outcomes were: (1) a composite endpoint of stroke, transient ischemic attack (TIA), peripheral arterial embolism, or silent cerebral lesions on magnetic resonance imaging (MRI) and (2) major bleeding complications. A random effects model was used to pool the safety and efficacy data across all included trials.


RESULTS
When compared to warfarin, there was an increased risk of the composite endpoint of stroke, TIA, peripheral arterial embolism, or silent cerebral lesions on MRI with NOACs as periprocedural anticoagulants for AF ablation [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.06-2.68]. Sub-group analysis revealed a higher risk of composite endpoint with dabigatran as a periprocedural anticoagulant for AF ablation (OR: 2.01, 95% CI: 1.19-3.39) whereas the risk was similar with rivaroxaban (OR: 0.90, 95% CI: 0.34-2.41). Sensitivity analysis after excluding silent cerebral lesions on MRI showed there was no increased risk of thromboembolic events with either dabigatran (OR: 1.69, 95% CI: 0.81-3.51) or rivaroxaban (OR: 0.70, 95% CI: 0.12-4.04). Risk of bleeding with NOACs was similar to warfarin (OR: 0.91, 95% CI: 0.62-1.34).


CONCLUSIONS
NOACs are comparable to warfarin in terms of bleeding complications. However, dabigatran therapy is potentially associated with a higher risk of silent cerebral lesions on MRI. The results of this study should be considered as hypothesis-generating and assessed further in prospective randomized clinical studies.
Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
Ajay
A
Vallakati
Division of Cardiovascular Diseases, State University of New York, Downstate Medical Center, Brooklyn, NY, USA. abhisheksharma4mamc@gmail.com.
Abhishek
A
Sharma
Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
Mohammed
M
Madmani
Division of Cardiovascular Diseases, Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS, USA.
Madhu
M
Reddy
Division of Cardiovascular Diseases, Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS, USA.
Arun
A
Kanmanthareddy
Division of Cardiovascular Diseases, Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS, USA.
Sampath
S
Gunda
Division of Cardiovascular Diseases, Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS, USA.
Dhanunjaya
D
Lakkireddy
Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
William R
WR
Lewis
Ablation; Atrial fibrillation; Bleeding; Complications; Meta-analysis; Novel oral anticoagulants (NOACs); Thromboembolism