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Original Investigation
November 23, 2016

Assessment of Use vs Discontinuation of Oral Anticoagulation After Pulmonary Vein Isolation in Patients With Atrial Fibrillation

Author Affiliations
  • 1Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
  • 2Arrhythmia Clinic, Skåne University Hospital, Lund, Sweden
  • 3Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
  • 4Department of Heart Failure and Valvular Disease, Skåne University Hospital, Lund, Sweden
  • 5Department for Coagulation Disorders, Lund University, Malmö, Sweden
  • 6Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala, Sweden
  • 7Department of Clinical Sciences, South Hospital, Karolinska Institute, Stockholm, Sweden
  • 8Arrhythmia Center Stockholm, Stockholm, Sweden
  • 9Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
  • 10Department of Cardiology, Faculty of Medicine and Health, Örebro University
  • 11Department of Cardiology, Linköping University Hospital, Linköping, Sweden
JAMA Cardiol. Published online November 23, 2016. doi:10.1001/jamacardio.2016.4179
Key Points

Question  Do patients with atrial fibrillation and risk factors for stroke benefit from oral anticoagulation therapy after pulmonary vein isolation?

Findings  In this nationwide cohort study of 1585 patients with atrial fibrillation, those with a CHA2DS2-VASc score of 2 or more who discontinued oral anticoagulation treatment after pulmonary vein isolation experienced more ischemic strokes compared with those who continued their oral anticoagulation treatment.

Meaning  Patients with atrial fibrillation and a CHA2DS2-VASc score of 2 or more may benefit from continuous oral anticoagulation treatment after pulmonary vein isolation to reduce the risk of stroke.

Abstract

Importance  Pulmonary vein isolation (PVI) is a recommended treatment for patients with atrial fibrillation, but it is unclear whether it results in a lower risk of stroke.

Objectives  To investigate the proportion of patients discontinuing anticoagulation treatment after PVI in association with the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65-74 years, sex category [female]) score, identify factors predicting stroke after PVI, and explore the risk of cardiovascular events after PVI in patients with and without guideline-recommended anticoagulation treatment.

Design, Setting, and Participants  A retrospective cohort study was conducted using Swedish national health registries from January 1, 2006, to December 31, 2012, with a mean-follow up of 2.6 years. A total of 1585 patients with atrial fibrillation undergoing PVI from the Swedish Catheter Ablation Register were included, with information about exposure to warfarin in the national quality register Auricula. Data analysis was performed from January 1, 2015, to April 30, 2016.

Exposures  Warfarin treatment.

Main Outcomes and Measures  Ischemic stroke, intracranial hemorrhage, and death.

Results  In this cohort of 1585 patients, 73.0% were male, the mean (SD) age was 59.0 (9.4) years, and the mean (SD) CHA2DS2-VASc score was 1.5 (1.4). Of the 1585 patients, 1175 were followed up for more than 1 year after PVI. Of these, 360 (30.6%) discontinued warfarin treatment during the first year. In patients with a CHA2DS2-VASc score of 2 or more, patients discontinuing warfarin treatment had a higher rate of ischemic stroke (5 events in 312 years at risk [1.6% per year]) compared with those continuing warfarin treatment (4 events in 1192 years at risk [0.3% per year]) (P = .046). Patients with a CHA2DS2-VASc score of 2 or more or those who had previously experienced an ischemic stroke displayed a higher risk of stroke if warfarin treatment was discontinued (hazard ratio, 4.6; 95% CI, 1.2-17.2; P = .02 and hazard ratio, 13.7; 95% CI, 2.0-91.9; P = .007, respectively).

Conclusions and Relevance  These findings indicate that discontinuation of warfarin treatment after PVI is not safe in high-risk patients, especially those who have previously experienced an ischemic stroke.

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