Key result
Rivaroxaban is linked to ~31% higher UFH requirements than warfarin, whereas dabigatran shows comparable needs.
Why the study?
Data were lacking regarding the effects of minimally interrupted direct oral anticoagulants on the intensity of intraprocedural anticoagulation during AF ablation.
Do minimally interrupted direct oral anticoagulants affect the required dose of unfractionated heparin and time-to-target ACT > 300 seconds compared to uninterrupted warfarin in patients undergoing atrial fibrillation ablation?
Cohort (n=269)
No
Do minimally interrupted direct oral anticoagulants affect the required dose of unfractionated heparin and time-to-target ACT > 300 seconds compared to uninterrupted warfarin in patients undergoing atrial fibrillation ablation?
Minimally interrupted dabigatran provides comparable intraprocedural anticoagulation responsiveness to uninterrupted warfarin during AF ablation, whereas minimally interrupted factor Xa inhibitors require higher heparin doses and longer times to achieve target ACT.
Supports minimally interrupted dabigatran for standard heparin dosing in AF ablation; leaves open differential DOAC effects in randomized trials.
Background Data are still lacking regarding the effects of minimally interrupted direct oral anticoagulants (MID) on the intensity of intraprocedural anticoagulation of atrial fibrillation (AF) ablation. Methods A total of consecutive 269 patients who undergone AF ablation were eligible for the study. All oral anticoagulants (OACs) were discontinued just one dose before the procedure except warfarin. We assessed the total required dose of UFH and time‐to‐target ACT > 300 seconds (TTA) for each of direct oral anticoagulant (DOAC) groups compared with the uninterrupted warfarin group. Results DOACs were used in 86% of the patients in the present study (dabigatran group (DG)‐17%, rivaroxaban group (RG)‐30%, apixaban group (AG)‐29%, and edoxaban group (EG)‐10%). DG and EG used comparable dose of total UFH to WG (WG vs DG; 206 ± 53 U/kg vs 231 ± 63 U/kg; P = .664, vs EG; 239 ± 67 U/kg; P = .335), while RG and AG required higher total UFH (WG vs RG; 206 ± 53 U/kg vs 270 ± 63 U/kg; P < .001, vs AG; 263 ± 62 U/kg; P < .001). TTA was significantly longer in RG (RG:73 ± 28 minutes vs WG:51 ± 25 minutes; P = .001), AG (AG:64 ± 26 minutes vs WG:51 ± 25 minutes; P = .02), and EG (EG:67 ± 34 minutes vs WG:51 ± 25 minutes; P = .02) than WG, whereas DG was comparable to WG (DG:51 ± 29 minutes vs WG:51 ± 25 minutes; P = NS). Especially, only RG demonstrated significantly slower increase in ACT than WG ( P = .013). In the multivariate analysis, warfarin or dabigatran use, age > 75 years, and body weight < 60 kg are clinical predictors for achieving TTA within 60 minutes (TTA‐60). Conclusion MID‐dabigatran was comparable to uninterrupted warfarin, whereas MID‐factor Xa inhibitors were not. MID is a feasible protocol; however, we should be aware of its effect on the intraprocedural anticoagulation and differences among DOACs in the responsiveness to heparin.
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Mizobuchi et al. (2019) conducted a cohort in atrial fibrillation (n=269). Minimally interrupted direct oral anticoagulants vs. Uninterrupted warfarin was evaluated on Total required dose of UFH and time-to-target ACT > 300 seconds. Minimally interrupted dabigatran required comparable total UFH to uninterrupted warfarin (231 vs 206 U/kg; P=0.664), whereas rivaroxaban required significantly higher UFH (270 U/kg; P<0.001).
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