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Dabigatran vs Warfarin for Radiofrequency Catheter Ablation of Atrial Fibrillation
Study Questions:
What is the safety and efficacy of dabigatran, compared to uninterrupted warfarin, for periprocedural anticoagulation in patients undergoing radiofrequency ablation (RFA) for atrial fibrillation (AF)?
Methods:
This was a case-control analysis in which 763 consecutive patients underwent RFA of AF using dabigatran (n = 191) or uninterrupted warfarin (n = 572) for periprocedural anticoagulation. Patients were instructed to take only the morning dose of dabigatran (150 mg) on the day before the procedure (24-30 hours preprocedure), and to skip the evening dose on the day before the procedure and the morning dose on the day of the procedure. Study endpoints were major bleeding, minor bleeding, and thromboembolic complications.
Results:
There were no thromboembolic complications in either group. The prevalence of major (4 of 191, 2.1%) and minor (5 of 191, 2.6%) bleeding complications in the dabigatran group were similar to those in the warfarin group (12 of 572, 2.1%; p = 1.0 and 19 of 572, 3.3%; p = 0.8, respectively). In the warfarin group, multivariable analysis demonstrated that preprocedural international normalized ratio (INR) (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.1-15.0; p = 0.04), clopidogrel use (OR, 4.2; 95% CI, 1.5-12.3; p = 0.01), and CHA2DS2-VASc score (OR, 1.4; 95% CI, 1.1-1.8; p = 0.01) were predictive of bleeding complications.
Conclusions:
When held after the morning dose on the day before RFA of AF, dabigatran appears to be as safe and effective as uninterrupted warfarin. Furthermore, concomitant use of clopidogrel, higher CHA2DS2-VASc score, and higher preprocedural INR (even in the therapeutic range of 2.0-3.0) are predictive of bleeding complications among patients receiving warfarin.
Perspective:
Although limited by a nonrandomized case-control design and a low event rate for thromboembolic events, this study does suggest that it is safe to perform RFA as long as dabigatran is administered per a specified protocol where it is held 24-30 hours prior to the procedure. This study also calls attention to the predictors of bleeding complications among patients receiving warfarin, notably INR (even within the therapeutic range). Such a finding may suggest that a safer INR window may be needed to be ‘narrower’ than 2.0-3.0, as acknowledged by the authors; this approach warrants further study.
Keywords: beta-Alanine, Benzimidazoles, Warfarin, Atrial Fibrillation, Ticlopidine, Catheter Ablation, Hemorrhage
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