Periprocedural Stroke and Bleeding Complications in Patients Undergoing Catheter Ablation of Atrial Fibrillation With Different Anticoagulation Management: Results From the “COMPARE” Randomized Trial

Study Questions:

Compared to interrupted warfarin therapy, is it safer to perform radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) during continuous warfarin therapy?


The subjects of this study were 1,584 patients (mean age 62 years) with AF and ≥1 risk factor for stroke. They were randomly assigned to undergo RFCA off warfarin with heparin bridging (n = 790) or on warfarin with international normalized ratio [INR] 2-3 (n = 794). The primary endpoint was thromboembolic (TE) events within 48 hours of RFCA.


TE events consisted of strokes or transient ischemic attacks, and were significantly more prevalent in the off-warfarin group (4.9%) than in the on-warfarin group (0.25%). Independent predictors of TE were warfarin discontinuation (odds ratio [OR], 13), CHADS2 score (OR, 5.4), longstanding persistent AF (OR, 4.7), and female gender (OR, 2.2). There was no significant difference in the prevalence of major bleeding events between the off-warfarin (0.76%) and on-warfarin (0.50%) groups. Minor bleeding events were significantly more common in the on-warfarin (22%) than off-warfarin (4.1%) group.


The authors concluded that it is safer to continue warfarin and perform RFCA of AF when the INR is 2-3 than to interrupt warfarin and use periprocedural heparin bridging.


Based on the results of prior nonrandomized studies, it already has become standard clinical practice in many electrophysiology laboratories to perform RFCA of AF during uninterrupted warfarin therapy. This randomized study provides high-quality evidence in support of this practice. In prior studies, most TE events were attributable to inadequate heparin therapy when the INR was still subtherapeutic. Continuous warfarin therapy eliminates this source of TE events.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Stroke, Warfarin, Heparin, Risk Factors, Catheter Ablation

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