| Background:After the Framingham cohort demonstrated strong association with atrial fibrillation(AF)in relation to thromboembolic events(TEs),countless trials have assessed various antithrombotic therapies including both oral anticoagulants(OAC)and antiplatelets to minimize the risk of TE.Risk stratification was developed for practitioners to assess the stroke and bleeding risks associated with antithrombotic therapy to determine which patients may benefit from specific treatment strategies.OAC therapy reduces TE yet substantially raises the risk of bleeding,inciting concern among practitioners.Following a successful CA,the current guidelines lack sufficient evidence as to which stroke risk assessment score OACs’benefits exceed the risks.Furthermore,increasing evidence shows OAC therapy is not being used as often as it should in eligible AF patients to lower their risk of stroke.Factors regarding inadequate anticoagulation and discontinuing anticoagulants include a history of catheter ablation and the use of aspirin(ASA),an antiplatelet frequently administered for the primary and secondary prevention of cardiovascular diseases and TE.While CA may lessen the burden of AF,there is currently insufficient data available to determine if patients can stop taking OACs following the treatment.Aims:(1)To examine the real-world risks and benefits of long-term OACs following the blanking-period post-CA via meta-analyzing the latest data pertaining to TE and major bleeding in patients on-OACs and off-OACs.Examine the various TE and bleeding types,encompassing intracranial hemorrhage(ICH),gastrointestinal bleeding(GI),intramuscular bleeding(IM),as well as other bleeding events following ablation for both comparison groups.Investigate if OAC continuation improves outcomes in accordance with the TE risk assessment score(CHA2DS2-VASc score).(2)To examine the effects of antithrombotic regimens following CA on TE and major bleeding outcomes in the current clinical environment.Analyze the aforementioned outcomes associated with TE and bleeding risk scores(i.e.,CHA2DS2-VASc and HAS-BLED scores).Methods:1:Systematic review and meta-analysis.PubMed,Google Scholar,Medline,and Scopus were searched to identify studies that compared continued and discontinued oral anticoagulation in post-ablation AF patients.Using RevMan(5.4)and STATA(17.0),summary odds ratios(OR)and 95%confidence intervals(CI)were computed via the random-effects.The results were tested for robustness using sensitivity analysis.2:Single-center retrospective,observational cohort study.Following the blanking period of the index AF C A,TE and bleeding outcomes were assessed in patients on low-dose daily aspirin(ASA,administered for the primary and secondary prevention of cardiovascular diseases and TE)in comparison to patients taking direct oral anticoagulants(DOAC)and no antithrombotic(No-AT)therapy.Results:In study 1,20 studies,including 22 429 participants(13 505 off-OAC),were examined.Analysis of TE events showed that OAC continuation was favored by stratified CHA2DS2-VASc score≥2(OR 1.86;95%CI:1.02-3.40;p=0.04).Sensitivity analysis indicated that this association was attenuated.The on-OAC arm saw a higher incidence of major bleeding(OR 0.16;95%CI:0.08-0.95;p<0.001),particularly ICH and GI;(OR 0.17;95%CI:0.08-0.36;p<0.001)and(OR 0.12;95%CI:0.04-0.32;p<0.001),respectively.In study 2,1340 patients who underwent ablation between January 2015 and April 2021 were retrospectively included for analysis.Three months(blanking-period)post-ablation,131 patients continued DOACs,1209 discontinued oral anticoagulants(249 on ASA and 960 on No-AT).Nine patients(3.6%)in the ASA group developed TE compared to 3 patients(2.3%)on DOACs and 9(0.9%)on No-AT(p=0.007).Six major bleeding events occurred,4(1.6%)in patients on ASA,a comparatively high rate relative to the other cohorts(p=0.006).There was no statistically significant difference in CHA2DS2-VASc or HAS-BLED scores of patients who suffered TE and major bleeding than those who did not.Conclusion:1.The findings support sustained anticoagulation in patients with a CHA2DS2-VASc score of ≥2 following the blanking period post-CA.It is necessary to conduct large RCTs to gather additional data for further analysis.Following a successful AF CA,long-term oral anticoagulation was associated with a greater risk of major bleeding,predominantly GI and ICH.The development of effective bleeding-prevention strategies and safer anticoagulation regimens should be prioritized.2.Compared to DOACs and No-AT,long-term low-dose daily aspirin used prophylactically for cardiovascular disease had no impact in preventing TE and may exacerbate major bleeding following the blanking period post-CA.It is imperative to encourage practitioners to further educate AF patients on efficient antithrombotic therapy since aspirin must no longer be seen as a modest alternative. |
PDF Full Text Request