Benefit of Uninterrupted DOACs vs. VKA During AF Ablation

Study Questions:

What is the benefit of uninterrupted direct oral anticoagulant (DOAC) versus uninterrupted vitamin K antagonist (VKA) use for patients undergoing catheter ablation for nonvalvular atrial fibrillation (AF)?


The authors performed a systematic review and meta-analysis of randomized controlled trials comparing uninterrupted DOAC versus uninterrupted VKA use in ablation procedures for AF. The outcomes assessed included major bleeding, minor bleeding, thromboembolism, and post-procedure silent cerebral infarctions.


Six randomized trials were included, consisting of 2,256 patients (72.7% male) undergoing ablation for nonvalvular AF. Uninterrupted DOAC therapy was associated with a lower risk of major bleeding (2.3% vs. 5.2%, relative risk [RR], 0.45; 95% confidence interval [CI], 0.20-0.99) as compared to uninterrupted VKA. There was no identified difference in minor bleeding (13.9% vs. 13.7%, RR, 1.12; 95% CI, 0.87-1.43), thromboembolism (0.4% vs. 0.7%, RR, 0.75; 95% CI, 0.26-2.14), or post-procedural silent cerebral infarctions (16.3% vs. 15.4%, RR, 1.09; 95% CI, 0.80-1.49).


The authors concluded that uninterrupted DOAC therapy for catheter ablation in AF appears to be safer than uninterrupted VKA therapy due to a decreased rate of major bleeding events.


Uninterrupted VKA has become a standard of therapy to prevent stroke while minimizing bleeding due to the use of bridging heparin in VKA-treated patients undergoing catheter ablation for AF. Now that DOAC therapy is first line for many patients with AF, multiple randomized trials have compared uninterrupted DOAC therapy to uninterrupted VKA therapy to explore safety outcomes. Most of these have been underpowered to detect important differences in major bleeding. This meta-analysis provides evidence that, in general, a strategy of uninterrupted DOAC therapy is associated with less major bleeding risk than uninterrupted VKA therapy. However, the CI for thromboembolic events is broad enough that claims of ‘similar outcomes’ cannot be fully assessed at this time. Nonetheless, in patients taking DOAC therapy for stroke prevention in AF, it is reasonable to continue DOAC therapy uninterrupted during their catheter ablation procedure rather than switching to warfarin or a heparin-based bridging protocol.

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

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Cerebral Infarction, Hemorrhage, Heparin, Risk, Secondary Prevention, Stroke, Thromboembolism, Vascular Diseases, Vitamin K, Warfarin

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