Abstract 3891: Should We Abandon The Paradigm Of Withholding Oral Anticoagulation In Paroxysmal Atrial Fibrillation?
Introduction Regarding antithrombotic treatment in atrial fibrillation (AF) it is commonly believed that anticoagulation may be withheld in paroxysmal AF controlled by antiarrhythmic therapy, because of low stroke risk. This study aims to describe stroke incidence and oral anticoagulation (OAC) management rationale in paroxysmal versus persistent AF patients.
Hypothesis Stroke risk is comparable between paroxysmal and persistent AF.
Methods In the Euro Heart Survey on AF (2003–2004), 1517 paroxysmal and 1167 persistent AF patients were enrolled. Incidence of ischemic stroke during 1 year follow-up was available in respectively 1136 and 883 patients. Definitions of paroxysmal and persistent AF were according to the ACC/AHA/ESC guidelines. Multivariable logistic regression was performed to assess the independent role of clinical type of AF regarding OAC prescription and stroke incidence.
Results At baseline, OAC prescription was lower in paroxysmal compared to persistent AF (51 vs 80%; p<0.001), and OAC prescription was still less likely in paroxysmal AF after correction for stroke and bleeding risk factors (OR=0.37 (0.27–0.49); p<0.001). A prior stroke was equally often reported (4.3% in paroxysmal vs 4.4% in persistent AF; p=0.837). Paroxysmal AF had a non-significant higher ischemic stroke incidence than persistent AF during 1 year follow-up (1.9 vs 1.3%; p=0.227), which was also the case when taking into account patient characteristics and ATT in multivariable analysis (OR=1.62 (0.76–3.44); p=0.213). At 1 year follow-up, 49% of paroxysmal and 70% of persistent AF patients received OAC. The reason to withhold OAC, despite the presence of at least 1 high-risk factor for stroke, was more frequently reported to be “no indication” in paroxysmal AF (36 vs 21%; p=0.001).
Conclusions The Euro Heart Survey is the first real-life study to report a comparable stroke risk in paroxysmal and persistent AF. Paroxysmal AF patients, however, had a lower chance of receiving OAC because of a presumed lower stroke risk. The assumption that stroke risk is lower in patients with paroxysmal AF is not confirmed. The results of our study lends significant evidence for the recommendation in the ACC/AHA/ESC guidelines to disregard type of AF when deciding on OAC prescription.