Physicians' Academy for Cardiovascular Education

Uninterrupted treatment with NOAC as alternative to VKA for ablation of AF

Uninterrupted edoxaban vs. vitamin K antagonists for ablation of atrial fibrillation: the ELIMINATE-AF trial

Literature - Hohnloser SH, Camm J, Cappato R et al. - Eur Heart J 2019: doi:10.1093/eurheartj/ehz190

Introduction and methods

Before, during and after ablation for atrial fibrillation (AF), patients are treated with systemic anticoagulant therapy to reduce the risk of thromboembolic events [1,2]. Data on continuous peri-procedural use of edoxaban during ablation in patients with AF are lacking. The ELIMINATE-AF trial therefore investigated the efficacy and safety of uninterrupted edoxaban vs. VKA in patients undergoing catheter ablation for AF.

The exploratory ELIMINATE-AF (March 2017 – Sept 2018) was a multinational, multicenter, randomized, open-label, parallel-group, blinded-endpoint evaluation (PROBE) trial including patients aged ≥18 years with documented non-valvular AF scheduled for their first or repeated catheter ablation for AF. Eligible patients were randomized 2:1 to receive either once-daily edoxaban 60 mg (or 30 mg if they met ≥1 criterion for dose reduction) or VKA. Maximum time between the last pre-ablation edoxaban dose and the ablation procedure was 18 hours. During ablation unfractionated heparin was administered. Administration of study drug was reinitiated >6 hours post-sheath removal after achieving adequate hemostasis and continued for 90 days post-ablation. In a sub-study silent cerebral lesions were assessed by performing MRI.

The modified intent-to-treat (mITT) population (n=602) included all randomized patients who received ≥1 dose of study drug. The mITT analysis was used for the primary and key secondary safety parameters. The per-protocol (PP) population (n=417) consisted of patients who received study drug and underwent catheter ablation. PP analysis and post-ablation period was used for the primary outcome parameter and key secondary efficacy parameters.

Primary study endpoint was time to first occurrence of all-cause death, stroke (ischemic, hemorrhagic or undetermined), or ISTH-defined major bleeding during the period from the end of the ablation procedure to the end of treatment (post-ablation period; 90 days). The primary safety endpoint was the time to the first occurrence of ISTH-defined major bleeding from the date of the first administration of study drug to the end of treatment.

Main results

Primary and safety endpoint

MRI-established cerebral microembolism


This study demonstrated that uninterrupted treatment with edoxaban represents an alternative to continuous VKA during and after catheter ablation in patients with AF. However, a limitation of the study is that it was exploratory and not powered to formally test superiority or noninferiority of edoxaban vs VKA.


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