Key result
In patients receiving NOACs undergoing atrial fibrillation ablation, adequate initial heparin dosages to achieve target activated clotting times were 120-130 U/kg, which is 10-20% higher than the 100 U/kg required for patients on warfarin.
Why the study?
Does an adjusted initial heparin dosage achieve adequate activated clotting time (ACT) in patients receiving NOACs undergoing atrial fibrillation ablation compared to those receiving warfarin?
RCT (n=360)
Randomly assigned to 110, 120, or 130 U/kg
No
Does an adjusted initial heparin dosage achieve adequate activated clotting time (ACT) in patients receiving NOACs undergoing atrial fibrillation ablation compared to those receiving warfarin?
Patients receiving NOACs require 10-20% higher initial heparin dosages (120-130 U/kg) compared to those on warfarin to achieve adequate periprocedural anticoagulation during AF ablation.
Adjust initial heparin dosing to 120-130 U/kg for NOAC patients during AF ablation; extends periprocedural anticoagulation guidance beyond warfarin-era protocols.
BACKGROUND AND OBJECTIVE: During atrial fibrillation ablation, heparin is required and is guided by the activated clotting time (ACT). Differences in the ACT before ablation and adequate initial heparin dosing in patients receiving non-vitamin K antagonist oral anticoagulants (NOACs) were examined. METHODS: Patients who received warfarin (control, N = 90), dabigatran etexilate (N = 90), rivaroxaban (N = 90) and apixaban (N = 90) were studied. A 100 U/kg dose of heparin was administered as a reliable control dose for warfarin, and the remaining patients were randomly administered 110, 120 or 130 U/kg of heparin in each NOAC group, followed by a continuous heparin infusion. RESULTS: Periprocedural thromboembolic and major bleeding were not observed. Minor bleeding occurred rarely without significant differences among the groups examined. Baseline ACTs were longer in the warfarin (152 ± 16 s) and dabigatran (153 ± 13 s) groups than in the rivaroxaban (134 ± 13 s) and apixaban (133 ± 20 s) groups. The initial bolus heparin dosages required to produce an ACT 15 min after the initial bolus that was identical to the control (333 ± 32 s) were 120 U/kg (318 ± 29 s) and 130 U/kg (339 ± 43 s) for dabigatran, 130 U/kg (314 ± 31 s) for rivaroxaban and 130 U/kg (317 ± 39 s) for apixaban. The NOAC groups required significantly larger doses of total heparin than the warfarin group. CONCLUSION: The baseline ACTs differed among the three NOAC groups. The results of the comparison with warfarin (the control) indicated that dosages of 120 or 130 U/kg for dabigatran, and 130 U/kg for rivaroxaban and apixaban, were adequate initial heparin dosages.
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Yamaji et al. (2016) conducted an RCT in Atrial Fibrillation (n=360). Heparin (with NOACs) vs. Heparin 100 U/kg (with warfarin) was evaluated on Activated clotting time (ACT) 15 min after initial bolus heparin administration. In patients receiving NOACs undergoing atrial fibrillation ablation, adequate initial heparin dosages to achieve target activated clotting times were 120-130 U/kg, which is 10-20% higher than the 100 U/kg required for patients on warfarin.
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