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This section covers cardioversion, ablation and PCI in patients with AF, discussing guideline recommendations and data from clinical studies
Cardioversion aims to re-establish a normal sinus rhythm in patients with AF, either by:1,2
Reported success rates of cardioversion vary:2
Evidence regarding the factors that predict successful cardioversion is limited:
AF recurs within 1 year in approximately half of patients who undergo successful cardioversion.1 Factors that have been identified as potentially predictive of AF recurrence include:3,5,8
Ablation procedures are performed on patients with AF to attempt to restore a normal sinus rhythm by destroying the cardiac tissue responsible for the arrhythmia:9
The ESC guidelines for the management of NVAF recommend:12
PCI with stent implantation is a common coronary revascularization procedure. Approximately 3 million people worldwide undergo PCI each year.13 PCI is required in patients with stable ischaemic heart disease or ACS.13 It is important that patients receive antiplatelet therapy after a PCI to reduce the risk of future ischaemic or atherothrombotic events, particularly stent-related thrombosis, recurrent MI, or cardiovascular death.13 However, the use of antiplatelet therapy increases the risk of bleeding events. For more information on the use of anticoagulants for patients with AF and PCI please see the article ‘Patients with AF Undergoing PCI’.
Recommendation | Grade of evidence |
---|---|
Catheter ablation is recommended in patients with symptomatic paroxysmal AF or persistent AF after one failed or intolerant antiarrhythmic drug who experience symptomatic, recurrent AF on antiarrhythmic drug therapy. This should be performed by an appropriately trained electrophysiologist at an experienced centre | IA |
Complete electrical isolation of the pulmonary veins is recommended during AF catheter-ablation procedures | IA |
Catheter ablation of AF should/may be considered as first-line rhythm control therapy to improve symptoms in selected patients with symptomatic paroxysmal AF as an alternative to antiarrhythmic drug therapy, taking into consideration patient choice, benefit and risk | IIB |
Catheter ablation is associated with an approximately 1% risk of stroke or TIA.11 Anticoagulation with a VKA(INR of 2.0 – 3.0) or NOAC ≥3 weeks before ablation may be considered.
Following AF ablation, warfarin or a NOAC should be continued for ≥2 months, and the decision to continue therapy long term is based on the patient’s stroke risk profile. 12
The electrical or pharmacological disruption of left atrium function during the cardioversion procedure is associated with a 5–7% incidence of thromboembolism, including stroke.14 By contrast, the risk is approximately 1% with adequate anticoagulation.15,16
Current guidelines recommend ≥3 weeks of adequate anticoagulation before cardioversion:12,17
After cardioversion, anticoagulation should be continued long term in patients based on their thromboembolic and bleeding risk profile.12,17
Recommendation | Grade of evidence |
---|---|
In patients with AF undergoing cardioversion, NOACs are recommended with at least similar efficacy and safety to warfarin | IA |
Effective oral anticoagulation is recommended for ≥3 weeks before cardioversion in all patients with AF | IB |
For patients with AF of >24-h duration, oral anticoagulant therapy should be continued for ≥4 weeks after cardioversion, (beyond 4 weeks, long-term OAC treatment is determined by the presence of stroke risk factors) | IB |
In patients at risk of stroke, OAC therapy, whether with dose-adjusted VKA (INR 2.0–3.0) or a NOAC, should be continued long term after cardioversion irrespective of the apparent maintenance of sinus rhythm or ‘first-diagnosis’ characterization of AF | IB |
The ESC guidelines recommend all NOACs for pre- and post-cardioversion anticoagulation therapy.
The use of dabigatran for cardioversion anticoagulation was based on a a subanalysis of the RE-LY trial because a relatively large number of patients planned for cardioversion were included in the study:18
Subanalyses of the phase III studies of rivaroxaban (ROCKET AF) and apixaban (ARISTOTLE) also indicated similar outcomes to the overall populations in patients receiving cardioversion, but there were relatively few of these patients in these trials:19,20
To date, there have been few studies regarding the use of NOACs during AF ablation:
Prospective clinical studies have been conducted to prospectively investigate NOAC use in patients undergoing cardioversion and catheter ablation.
The X-VeRT trial of rivaroxaban (NCT01674647) was the first prospective study of a NOAC to report results in the cardioversion setting (N=1504):24
The ENSURE-AF study (NCT02072434)25 and the EMANATE trial (NCT02100228)26 have reported results ofwith edoxaban and apixaban, respectively.
The ENSURE-AF trial, compared edoxaban 60 mg per day with enoxaparin-warfarin in patients (N=2199) undergoing electrical cardioversion of NVAF.25
In the EMANATE trial, patients (N=1500) with AF undergoing cardioversion were randomizsed to receive apixaban 5 mg twice daily, or heparin/VKA.26
It is important to note that these studies, like X-VeRT, were not powered to show significant differences in either safety or efficacy.
The safety of rivaroxaban in patients with AF undergoing catheter ablation was investigated in the open-label VENTURE-AF study (NCT01729871), which was the first prospective, randomized study of a NOAC in this setting:27
Since the rivaroxaban study, open-label, prospective studies assessing the safety and efficacy of apixaban (AXAFA-AFNET 5 trial [NCT02227550])28,29 and dabigatran (RE-CIRCUIT trial [NCT02348723])30 have been completed in patients with AF undergoing catheter ablation.
The ELIMINATE AF (NCT02942576) trial assessed the safety and efficacy of uninterrupted edoxaban 60 mg once daily (30 mg once daily in patients indicated for a dose reduction) compared with a (VKA) in patients with NVAF undergoing catheter ablation.31
For a summary of clinical trials that explored the use of NOACs in patients with NVAF undergoing PCI please see the article ‘Patients with AF Undergoing PCI’.