Periprocedural Management of New Oral Anticoagulants in Patients Undergoing Atrial Fibrillation Ablation
A 68-year-old woman with well-controlled hypertension is having 3 to 4 episodes of paroxysmal atrial fibrillation (AF) each month. Despite a ventricular rate of 80 to 100/min while in AF, she complains of palpitations, chest discomfort, and light-headedness. Oral flecainide failed to improve her symptoms, and she refuses to take amiodarone because of concerns about its potential toxicity. She was started on dabigatran (150 mg twice daily) for stroke prevention; her creatinine clearance was calculated at 92 ml/min. AF ablation has been scheduled, and advice is needed regarding periprocedural dabigatran management.
AF, the most common cardiac arrhythmia, is a major cause of stroke.1 Although many AF patients are asymptomatic or have adequate symptom palliation with rate-controlling medications, some require treatment strategies aimed at maintaining sinus rhythm. In the United States, it is estimated that >150 000 AF patients undergo catheter ablation each year in an attempt to achieve rhythm control.2 Originally targeted to younger AF patients without structural heart disease, catheter ablation is performed in a broader population now that outcomes have improved. Consequently, the number of ablation procedures performed is expected to increase exponentially over the next decade.
Current guidelines recommend anticoagulant prophylaxis in all but the lowest risk AF patients. Until recently, vitamin K antagonists, such as warfarin, were the only option for stroke prevention in such patients. This situation changed with the introduction of new oral anticoagulants (NOACs), which target thrombin or factor Xa. With a more predictable anticoagulant response and shorter half-lives than warfarin, NOACs have the potential to streamline periprocedural management in AF patients undergoing ablation. However, data with NOACs in this setting are limited, and at times contradictory, which complicates their integration into routine practice in patients undergoing catheter ablation.
Comparison of the Pharmacological Properties of the NOACs With Those of Warfarin
NOACs have pharmacological properties that distinguish them from warfarin. These are summarized …