When to Stop Dabigatran Anticoagulation Treatment Before Catheter Ablation in Patients with Atrial Fibrillation?
Catheter ablation is now a standard method of treating atrial fibrillation. Its most common complications are bleeding and thromboembolism. The aim of the analysis of 2 clinical studies presented below, whose conclusions were recently published, was to determine the optimal timing of stopping dabigatran anticoagulation treatment before this procedure.
Analyzed Studies
Data from the prospective randomized clinical studies RE-CIRCUIT and ABRIDGE-J involving patients undergoing catheter ablation for non-valvular paroxysmal or persistent atrial fibrillation were analyzed.
The RE-CIRCUIT study included a total of 635 patients who were on dabigatran at a dose of 150 mg twice daily (n = 315) or warfarin (n = 318) titrated according to INR. Anticoagulation treatment was not interrupted periablation in these patients.
The ABRIDGE-J study included a total of 442 patients. Dabigatran at a dose of 150 or 110 mg (e.g., in cases of chronic renal insufficiency) twice daily was used by 220 patients, and warfarin titrated according to INR was used by 222 persons. Use of dabigatran was interrupted before the procedure (up to 2 doses were missed), unlike warfarin. In case this interval lasted ≥ 24 hours, bridging with heparin was recommended. After the procedure, standard dabigatran use was resumed.
Based on the interval when the last dose of dabigatran was administered before catheter ablation, patients from both studies were divided into 3 groups (< 8 hours, n = 258; 8–24 hours, n = 191; > 24 hours, n = 86) for the purposes of the analysis. The primary monitored parameter was the proportion of patients with significant bleeding within 8 weeks of the procedure.
Results
Significant bleeding was observed in 5 patients (1.9%) in the “< 8 hours” group (3.5%; 2 cardiac tamponades/hemopericardium, 2 vascular access site bleedings on the day of the procedure, and 1 gastrointestinal bleeding after 36 days) and 3 patients in the “> 24 hours” group (1 hemopericardium, 1 intraperitoneal bleeding, and 1 vascular access site bleeding on the day of the procedure or the day after). No such event occurred in the 8–24 hours group (p = 0.026). No thromboembolic event was reported in any patient.
Discussion and Conclusion
As previously indicated by the above-mentioned RE-CIRCUIT and ABRIDGE-J studies, the use of dabigatran is associated with a lower incidence of bleeding complications compared to warfarin. A low incidence of bleeding complications was observed in all 3 groups of patients interrupting dabigatran use before ablation.
The occurrence of bleeding episodes in the “< 8 hours” group could be attributed to the persistent anticoagulant effect of dabigatran, which might be advantageous in patients at higher risk of thromboembolism (the analyzed data are from patients with low risk, specifically with a CHADS2 score ≤ 2). The difference between the “< 8 hours” and “8–24 hours” groups was not statistically significant. The highest proportion of patients with bleeding complications was observed in the “> 24 hours” group, where there was significantly higher heparin consumption.
Therefore, it is recommended to interrupt dabigatran use in patients with atrial fibrillation less than 24 hours before catheter ablation if they have low thromboembolic risk. In the future, further studies not only with dabigatran but also with other new/direct oral anticoagulants (NOACs/DOACs) will undoubtedly be necessary.
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Source:
Kimata A., Nogami A., Yamasaki H. et al. Optimal interruption time of dabigatran oral administration to ablation (O-A time) in patients with atrial fibrillation: integrated analysis of 2 randomized controlled clinical trials. J Cardiol 2021 Jun; 77 (6): 652–659, doi: 10.1016/j.jjcc.2020.12.010.
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