Continuous DOAC is safe and effective in patients with AF undergoing ablation
Apixaban in patients at risk of stroke undergoing atrial fibrillation ablationLiterature - Kirchhof P, Haeusler KG, Blank B, et al. - Eur Heart J 2018;published online ahead of print
Introduction and methods
Ablation in patients with atrial fibrillation (AF) is associated with a risk of stroke and major bleeding [1-3]. Continuous oral anticoagulation is recommended in these patients to reduce the risk of embolic events [1,3,4]. Continuous apixaban in this setting has not been tested. Declined cognitive function and acute brain lesions have been associated with AF ablation, but this has not been studied in controlled clinical trials.
633 Patients with at least one established stroke risk factor, who were scheduled for a first AF ablation were, were randomized to receive continuous apixaban 5 mg bid or continuous VKA therapy (warfarin, phenprocoumon, acenocoumarol) in the Anticoagulation using the direct factor Xa inhibitor apixaban during Atrial Fibrillation catheter Ablation: comparison to VKA therapy (AXAFA – AFNET 5) trial.
The primary outcome was the composite of all-cause death, stroke, or major bleeding. Major bleeding was defined according to the Bleeding Academic Research Consortium (BARC ≥2) . Cognitive function was assessed in all patients by Montreal Cognitive Assessment (MoCA)  and the prevalence and number of brain lesions by MRI were analyzed in a sub-study.
- Apixaban was non-inferior to VKA (a difference of -0.38%, 90%CI:-4.0% to 3.3%, non-inferiority P=0.0002) for the primary outcome.
- There was no interaction between stoke, bleeding risk factors and treatment groups.
- After 90 days, mild cognitive dysfunction was improved; MoCA increased by a median of 1.0 unit (90%CI: -1.0 to 2.0, P=0.005) with no differences between groups.
- No differences in acute brain lesions were detected between groups (P=0.635) in a total of 323 analyzable MRIs. Cognitive function was not different in those with or without acute brain lesions.
In patients with increased risk of stroke undergoing AF ablation, continuous apixaban therapy was safe and effective compared to VKA treatment with respect to stroke, bleeding, cognitive function and brain lesions. More research is needed to reduce ablation-related acute brain lesions.