James V Freeman1, Peter Shrader2, Karen S Pieper2, Larry A Allen3, Paul S Chan4, Gregg C Fonarow5, Bernard J Gersh6, Peter R Kowey7, Kenneth W Mahaffey8, Gerald Naccarelli9, James A Reiffel10, Daniel E Singer11, Alan S Go12, Elaine M Hylek13, Benjamin A Steinberg14, Eric D Peterson2,15, Jonathan P Piccini2,15. 1. Yale University School of Medicine, New Haven, CT (J.V.F.). 2. Duke Clinical Research Institute, Durham, NC (P.S., K.S.P., E.D.P., J.P.P.). 3. Division of Cardiology, University of Colorado School of Medicine, Aurora (L.A.A.). 4. Saint Luke's Mid America Heart Institute, Kansas City and Department of Medicine, University of Missouri-Kansas City, MO (P.S.C.). 5. UCLA David Geffen School of Medicine, Los Angeles, CA (G.C.F.). 6. Mayo Clinic, Rochester, MN (B.J.G.). 7. Lankenau Institute for Medical Research, Wynnewood, PA (P.R.K.). 8. Stanford University School of Medicine, Palo Alto, CA (K.W.M.). 9. Penn State University School of Medicine, Hershey, PA (G.N.). 10. Columbia University College of Physicians and Surgeons, NY (J.A.R.). 11. Harvard Medical School and Massachusetts General Hospital, Boston (D.E.S.). 12. Division of Research, Kaiser Permanente Northern California, Oakland, CA (A.S.G.). 13. Boston University School of Medicine, MA (E.M.H.). 14. University of Utah School of Medicine, Salt Lake City (B.A.S.). 15. Duke University School of Medicine, Durham, NC (E.D.P., J.P.P.).
Abstract
BACKGROUND: Studies evaluating the effects of atrial fibrillation (AF) catheter ablation versus antiarrhythmic therapy on outcomes have shown mixed results. In addition, guidelines recommend continuing oral anticoagulation (OAC) after ablation for those at risk of stroke, but real-world data are lacking. METHODS: We evaluated outcomes including death, myocardial infarction, stroke or systemic embolism, intracranial bleeding, major bleeding, and hospitalization in patients undergoing AF ablation compared with a propensity score matched cohort of patients treated with anti-arrhythmic medications only in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation registries. Cox proportional hazards regression was performed to evaluate the association between AF ablation and outcomes. We then evaluated patterns of treatment with OAC among AF ablation patients. RESULTS: Among 21 595 patients, 1190 (6%) underwent de novo AF ablation. Our propensity score-matched cohort included 1087 patients who underwent AF ablation matched 1:1 with 1087 patients treated with antiarrhythmic medications only. There were no significant differences in the risk of all-cause and cardiovascular death, and most other major adverse cardiovascular and neurological events. AF catheter ablation was associated with an increased risk of all-cause hospitalization during follow-up (hazard ratio, 1.24 [95% CI, 1.05-1.46]), particularly in the first 3 months (the standard blanking period) after the procedure. Among those who underwent AF ablation with a CHA2DS2 VASc score ≥2 for men and ≥3 for women, 23% had OAC discontinued after ablation. Among those who discontinued OAC, the median time to discontinuation was 6.2 months. CONCLUSIONS: In this large US national registry, we found no difference in adjusted rates of cardiovascular or all-cause death between patients treated with AF catheter ablation and antiarrhythmic medications only. Notably, discontinuation of OAC after ablation remains relatively common despite guideline recommendations for continued stroke prevention therapy in patients at risk of stroke.
BACKGROUND: Studies evaluating the effects of atrial fibrillation (AF) catheter ablation versus antiarrhythmic therapy on outcomes have shown mixed results. In addition, guidelines recommend continuing oral anticoagulation (OAC) after ablation for those at risk of stroke, but real-world data are lacking. METHODS: We evaluated outcomes including death, myocardial infarction, stroke or systemic embolism, intracranial bleeding, major bleeding, and hospitalization in patients undergoing AF ablation compared with a propensity score matched cohort of patients treated with anti-arrhythmic medications only in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation registries. Cox proportional hazards regression was performed to evaluate the association between AF ablation and outcomes. We then evaluated patterns of treatment with OAC among AF ablation patients. RESULTS: Among 21 595 patients, 1190 (6%) underwent de novo AF ablation. Our propensity score-matched cohort included 1087 patients who underwent AF ablation matched 1:1 with 1087 patients treated with antiarrhythmic medications only. There were no significant differences in the risk of all-cause and cardiovascular death, and most other major adverse cardiovascular and neurological events. AF catheter ablation was associated with an increased risk of all-cause hospitalization during follow-up (hazard ratio, 1.24 [95% CI, 1.05-1.46]), particularly in the first 3 months (the standard blanking period) after the procedure. Among those who underwent AF ablation with a CHA2DS2 VASc score ≥2 for men and ≥3 for women, 23% had OAC discontinued after ablation. Among those who discontinued OAC, the median time to discontinuation was 6.2 months. CONCLUSIONS: In this large US national registry, we found no difference in adjusted rates of cardiovascular or all-cause death between patients treated with AF catheter ablation and antiarrhythmic medications only. Notably, discontinuation of OAC after ablation remains relatively common despite guideline recommendations for continued stroke prevention therapy in patients at risk of stroke.
Authors: Elaine Y Wan; Hamid Ghanbari; Nazem Akoum; Zachi Itzhak Attia; Samuel J Asirvatham; Eugene H Chung; Lilas Dagher; Sana M Al-Khatib; G Stuart Mendenhall; David D McManus; Rajeev K Pathak; Rod S Passman; Nicholas S Peters; David S Schwartzman; Emma Svennberg; Khaldoun G Tarakji; Mintu P Turakhia; Anthony Trela; Hirad Yarmohammadi; Nassir F Marrouche Journal: Cardiovasc Digit Health J Date: 2021-07-10