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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e88

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

short term (90 days) after ablation.24 Although the evidence base for short-term antiarrhythmic drug therapy after ablation is robust, the decision to use short-term antiarrhythmic drug therapy should be based on the patient’s risk and informed by SDM.

8.4.4 Anticoagulation Therapy Before and After Catheter Ablation

Recommendations for Anticoagulation Therapy Before and After Catheter Ablation Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-NR 1 In patients on warfarin who are undergoing

catheter ablation of AF, catheter ablation should be performed on uninterrupted therapeutic anticoagulation with a goal INR of 2.0 to 3.0.1

1 A 2 In patients on a DOAC who are undergoing catheter

ablation of AF, catheter ablation should be performed with either continuous or minimally interrupted oral anticoagulation.2–10

1 B-NR 3 In patients who have undergone catheter ablation of

AF, oral anticoagulation should be continued for at least 3 months after the procedure with a longer duration determined by underlying risk.11

1 B-NR 4 In patients who have undergone catheter ablation of

AF, continuation of longer-term oral anticoagulation should be dictated according to the patients’ stroke risk (eg, CHA2DS2-VASc score ≥2).11–17

Synopsis Catheter ablation has been demonstrated in randomized clinical trials to reduce arrhythmia burden improve QOL and, in select populations, it has been shown to improve cardiovascular outcomes. Complications after catheter ablation are infrequent, yet the risk of thromboembolic events is increased after ablation. The risk of stroke in the first 30 days after ablation is 0.8%.18 Thus, oral anticoagulation before, during, and after catheter ablation procedures is paramount. Recommendation-Specific Supportive Text 1.	 All patients undergoing catheter ablation require

intraprocedural intravenous anticoagulation with heparin or direct thrombin inhibitors in those with heparin allergies. Management of oral anticoagulation during these procedures is also critically important. In those patients undergoing catheter ablation of AF who are taking warfarin for their oral anticoagulation, evidence from observational studies and randomized trial data suggest that optimal efficacy and safety is achieved with uninterrupted warfarin. Patients undergoing catheter ablation of AF who have subtherapeutic INRs or interrupted warfarin have more evidence of silent cerebral ischemic events on brain magnetic resonance imaging after the procedure.1 In the COMPARE (Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation [AF] Patients Undergoing Catheter Ablation) trial, interruption of warfarin was highly associated with periprocedural thromboembolic events (OR, 13 [95% CI, 3.1-55.6]; P<0.001).1 Patients treated with uninterrupted warfarin had lower rates of thromboembolic events (5% versus 0.25%; P<0.001) and lower rates of periprocedural bleeding compared with those in whom warfarin was stopped or interrupted. 2.	 Although uninterrupted warfarin is superior to

interrupted warfarin among persons undergoing catheter ablation of AF, meta-analyses have demonstrated lower risks of major bleeding with uninterrupted direct oral anticoagulation compared with uninterrupted vitamin K antagonism.2 Many randomized trials have been completed that compare uninterrupted DOACs versus uninterrupted VKAs, including trials of apixaban,3,4 dabigatran,5 edoxaban,6 and rivaroxaban.7 In aggregate, these trials have demonstrated the noninferiority of uninterrupted direct-acting oral anticoagulation compared with uninterrupted vitamin K antagonism. Several randomized trials also compare minimally interrupted direct-acting oral anticoagulation versus uninterrupted direct-acting oral anticoagulation8 or uninterrupted vitamin K antagonism.9 These clinical trials and meta-analyses suggest that outcomes with minimally interrupted direct-acting oral anticoagulation are not different compared with continuous anticoagulation.10

3 The risk of thromboembolic and stroke events

increases after ablation due to vascular and cardiac instrumentation, release of tissue factor, and myocardial injury. Most randomized clinical trials of catheter ablation that demonstrate a low risk of periprocedural stroke mandated oral anticoagulation for a minimum of 2 months after ablation to reduce the risk of stroke, regardless of CHA2DS2- VASc score.19

4 Greater burden or time in AF is associated with

higher rates of stroke.12–14 Accordingly, reducing exposure to AF via catheter ablation might be expected to reduce the risk of stroke. Although some observational studies have identified lower stroke risk after catheter ablation,15,16 randomized clinical trials of catheter ablation have not demonstrated reductions in stroke.11,17 Observational data regarding the risk of stroke after catheter ablation of AF are mixed and vary across study design and methods. For example, in an analysis of 4 050 patients undergoing catheter ablation with a CHA2DS2-VASc score ≥2 in Denmark, the risk after ablation was low and comparable in those who did (0.93/100 patient years) and did not (0.97/100 patient years) discontinue anticoagulation >3 months after ablation.20 In contrast, a study of 6 866 patients who underwent catheter ablation of AF in US clinical practice found that the risk of stroke was

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