Meta-analysis of efficacy and safety of apixaban and uninterrupted apixaban therapy compared to vitamin K antagonists in patients undergoing catheter ablation for atrial fibrillation
- 883 Downloads
Apixaban is a Factor Xa inhibitor increasingly being used for stroke prevention in atrial fibrillation (AF). Although several studies have been done, the efficacy and safety of apixaban during the peri-procedural period of AF ablation remains unclear. We sought to systematically review pooled data from these various studies to evaluate thromboembolic and bleeding risks in patients undergoing catheter ablation for AF who are treated with apixaban (interrupted and uninterrupted).
Studies comparing anticoagulation with apixaban or vitamin K antagonists (VKA) in patients undergoing ablation for AF were identified via an electronic search of MEDLINE, EMBASE, clinical trials.gov, and Cochrane Library from inception to January 2016. Study-specific risk ratios were calculated and combined with a fixed-effects model meta-analysis.
In the analysis of 2100 pooled patients, thromboembolic complications (TE) occurred in 14/778 (1.80 %) patients in the apixaban group (AG) compared to 20/1322 patients in the VKA group (RR 1.03, 95 % CI 0.55–1.90, p = 0.93, I 2 = 0 %). Major bleeding occurred in 9/778 (1.2 %) of the AG compared to 20/1322 (1.51 %) in the VKA group (RR 1.03, 95 % CI 0.55–1.90, p = 0.93, I 2 = 0 %). In uninterrupted apixaban group (uAG), TE occurred in 4/585 (0.68 %) patients in the uAG compared to 6/910 (0.66 %) in VKA group (RR 0.86, 95 % CI 0.25–2.95, p = 0.81, I 2 = 0 %). Major bleeding occurred in 5/585 (0.85 %) in uAG compared to 7/910 (0.77 %) in the VKA group (RR 1.20, 95 % CI 0.37–3.88, p = 0.76, I 2 = 0 %).
Our study demonstrates patients treated with apixaban and VKA during the peri-procedural period for AF ablation have similar rates of TE and bleeding complications. Interrupted and uninterrupted apixaban strategies were associated with similar outcomes.
KeywordsApixaban Atrial fibrillation Catheter ablation
Authors AU, PS, and PK conceived, designed, and participated in the abstraction, analysis, interpretation, and drafting of the initial manuscript. Authors SH, MG, GV, SS, and DW analyzed, interpreted, and provided intellectual content, edited the subsequent draft, and approved the final manuscript.
Compliance with ethical standards
Conflicts of interest
Anene Ukaigwe, MD—None.
Pragya Shrestha, MD—None.
Paras Karmacharya, MD—None.
Sarah K. Hussain, MD—Consulting, Speaking Honoraria, Biosense Webster and Speaking Honoraria, Medtronic.
Soraya Samii, MD—None.
Mario D. Gonzalez, MD—Consulting, Speaking Honoraria, Biosense Webster and Biosense Janssen.
Deborah Wolbrette, MD—None.
Gerald V. Naccarelli, MD—Consulting, Glaxo-Smith-Kline, Pfizer, Sanofi, Boehringer-Ingelheim, Bristol Myers Squibb, Otsuka, Janssen, Daiichi-Sankyo, Xention, Astra-Zeneca.
- 4.January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64:e1–76.CrossRefPubMedGoogle Scholar
- 5.Di Biase L, Burkhardt JD, Santangeli P, et al. Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the role of coumadin in preventing thromboembolism in atrial fibrillation (AF) patients undergoing catheter ablation (COMPARE) randomized trial. Circulation. 2014;129:2638–44.CrossRefPubMedGoogle Scholar
- 7.Amin A, Bruno A, Trocio J, Lin J, Lingohr-Smith M. Comparison of differences in medical costs when new oral anticoagulants are used for the treatment of patients with non-valvular atrial fibrillation and venous thromboembolism vs warfarin or placebo in the US. J Med Econ. 2015;18:399–409.CrossRefPubMedGoogle Scholar
- 8.Bin Abdulhak AA, Kennedy KF, Gupta S, Giocondo M, Ramza B, Wimmer AP. Effect of pre-procedural interrupted apixaban on heparin anticoagulation during catheter ablation for atrial fibrillation: a prospective observational study. J Interv Card Electrophysiol. 2015;44:91–6. Int J Arrhythm Pacing.CrossRefPubMedGoogle Scholar
- 11.Kuwahara T, Abe M, Yamaki M, et al. Apixaban versus warfarin for the prevention of periprocedural cerebral thromboembolism in atrial fibrillation ablation: multicenter prospective randomized study. J Cardiovasc Electrophysiol. 2016.Google Scholar
- 12.Iriki Y. Evaluation of safety and efficacy of perioperative use of rivaroxaban and apixaban in catheter ablation for atrial fibrillation. Eur Heart J. 2015;36 suppl 1:687.Google Scholar
- 14.Di Biase L, Lakkireddy D, Trivedi C, et al. Feasibility and safety of uninterrupted periprocedural apixaban administration in patients undergoing radiofrequency catheter ablation for atrial fibrillation: results from a multicenter study. Heart Rhythm Off J Heart Rhythm Soc. 2015;12:1162–8.CrossRefGoogle Scholar
- 17.Nilsson KR. Apixaban is a safe alternative to uninterrupted warfarin during catheter ablation of atrial fibrillation. Europace. 2015;17:iii141.Google Scholar
- 18.Osaka Y. Uninterrupted use of ribaroxaban and apixaban for radiofrequency catheter ablation of atrial fibrillation: comparison with warfarin. Heart Rhythm. 2015;12:S469.Google Scholar
- 19.Anon. Ottawa Hospital Research Institute. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 1 Feb 2016.
- 21.Yoshimura A, Iriki Y, Ichiki H, et al. Evaluation of safety and efficacy of periprocedural use of rivaroxaban and apixaban in catheter ablation for atrial fibrillation. J Cardiol. 2016.Google Scholar
- 22.Anon. Cochrane Handbook for Systematic Reviews of Interventions. Available at: http://handbook.cochrane.org/. Accessed 1 Feb 2016.
- 24.Camm AJ, Lip GYH, De Caterina R, et al. 2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation—developed with the special contribution of the European Heart Rhythm Association. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol. 2012;14:1385–413.Google Scholar
- 25.Sticherling C, Marin F, Birnie D, et al. Antithrombotic management in patients undergoing electrophysiological procedures: a European Heart Rhythm Association (EHRA) position document endorsed by the ESC Working Group Thrombosis, Heart Rhythm Society (HRS), and Asia Pacific Heart Rhythm Society (APHRS). Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol. 2015;17:1197–214.Google Scholar
- 26.Nairooz R, Ayoub K, Sardar P, et al. Uninterrupted new oral anticoagulants compared with uninterrupted vitamin K antagonists in ablation of atrial fibrillation: a meta-analysis. Can J Cardiol. 2015.Google Scholar
- 33.Anon. Apixaban during atrial fibrillation catheter ablation: comparison to vitamin K antagonist therapy—full text view—ClinicalTrials.gov. Available at: https://clinicaltrials.gov/ct2/show/NCT02227550?term=apixaban+and+atrial+fibrillation&rank=2. Accessed 1 Feb 2016.
- 34.Anon. Apixaban evaluation of interrupted or uninterrupted anticoagulation for ablation of atrial fibrillation—full text view—ClinicalTrials.gov. Available at: https://clinicaltrials.gov/ct2/show/NCT02608099?term=apixaban+and+atrial+fibrillation&rank=1. Accessed 1 Feb 2016.