Antikoagulationssituation bei hohem thromboembolischem Risiko nach Vorhofflimmerablation: Daten des Ablations-Qualitätsregisters

Zusammenfassung

Hintergrund und Fragestellung: Die Katheterablation bei Vorhofflimmern (VHF) hat als kurative Therapie von medikamentös therapierefraktärem VHF an Bedeutung gewonnen. Um nach erfolgreicher Ablation Thromboembolien zu vermeiden ist die dauerhafte orale Antikoagulation in Abhängigkeit vom CHA₂DS₂-VASc-Score indiziert. Wir untersuchten die Antikoagulationssituation ein Jahr nach Ablation bei erhöhtem thromboembolischem Risiko und identifizierten Determinanten, die zur Unterversorgung mit einer oralen Antikoagulation führen.

Methodik: Zwischen Januar 2007 und Januar 2010 wurden in 52 deutschen Zentren insgesamt 13 092 Patienten in ein prospektives, multizentrische Register eingeschlossen. 41 von diesen Zentren führten Katheterablation bei VHF durch. In diese Analyse wurden nur Patienten eingeschlossen, die nach Katheterablation bei VHF mit einer oralen Antikoagulation entlassen wurden und einen CHA₂DS₂-VASc-Score von mindestens 2 aufwiesen. Ein zentralisiertes 1-Jahres-Follow-up wurde telefonisch durchgeführt. Der Verzicht auf orale Antikoagulanzien trotz prinzipiell gegebener Indikation im 1-Jahres-Follow-Up wurde als bewusstes Absetzen interpretiert.

Ergebnisse: 1300 Patienten erfüllten die Einschlusskriterien. Ein Jahr nach Vorhofflimmerablation waren nur noch 51,8 % der Patienten mit einem CHA₂DS₂-VASc-Score von ≥ 2 antikoaguliert. Als signifikante Determinanten für das Absetzen trotz gegebener Indikation wurde die Rezidivfreiheit im Follow-Up (Adjustierte Odds Ratio [OR] 2,14; 95 %-Konfidenzintervall [KI] 1,73–2,66; P < 0,001) und paroxysmales VHF (OR 1,53; 95 %-KI 1,29–1,81; P < 0,001) identifiziert. Faktoren, die eine Fortführung der oralen Antikoagulation positiv beeinflussen sind das Patientenalter (OR je 10 Jahre: 0,79; 95 %-KI 0,68–0,91; P = 0,002), Herzklappenvitien (OR 0,67; 95 %-KI 0,48–0,92; P = 0,013), das Vorhandensein eines aktiven Herzrhythmusimplantates (OR 0,55; 95 %-KI 0,41–0,74; P < 0,001) sowie neurologische Ereignisse stationär oder im Follow-Up (OR 0,40; 95 %-KI 0,18–0,88; P = 0,022).

Folgerung: Fast die Hälfte der Patienten mit einer Indikation zur oralen Antikoagulation wird ein Jahr nach Katheterablation bei VHF nicht mehr leitliniengerecht therapiert. Paroxysmales VHF oder subjektive Rezidivfreiheit sind signifikant mit einem Absetzen der oralen Antikoagulation assoziiert.

Abstract

Background: Catheter ablation (CA) for atrial fibrillation (AF) is an effective therapeutic option for the treatment of symptomatic drug-refractory AF. According to current guidelines, the prevention of stroke and embolism is the most important therapeutic goal in AF and the recommendations for anticoagulation (OAC) after successful CA are based upon the CHA₂DS₂-VASc-Score [3]. The aim of this study was to evaluate the use of OAC in patients with a high risk for thromboembolic events 1 year after CA and to identify predictor variables for discontinuation of OAC.

Methods: Between January 2007 and January 2010 13092 patients were enrolled in the study. A total of 52 German electrophysiological centers agreed to participate in this prospective multicenter registry. 41 centers included patients undergoing CA for AF. Analysis included patients who were discharged with OAC after CA and had a CHA₂DS₂-VASc-Score ≥ 2. A centralized 1 year follow-up (FU) was conducted via telephone.

Results: 1300 patients fulfilled the inclusion criteria. One year after CA 51.8 % of these patients were on OAC. Factors significantly associated with discontinuation of OAC included no AF recurrence in FU (adjusted odds ratio (OR): 2.14, [95 % confidence interval (CI): 1.73–2.66], P < 0.001) and paroxysmal AF (OR: 1.53 [95 % CI: 1.29–1.81], P < 0.001). Factors associated with continuation of OAK were patient age (OR per 10 years: 0.79 [95 % CI: 0.68–0.91], P = 0.002), valvular heart disease (OR: 0.67 [95 % CI: 0.48–0.92], P = 0.013), an implanted pacemaker, defibrillator or a cardiac resynchronization therapy system (OR: 0.55 [95 % CI: 0.41–0.74], P < 0.001) and neurological events in hospital or during FU (OR: 0.40 [95 % CI: 0.18–0.88], P < 0.022).

Conclusion: Almost half of the patients with an indication for OAC are not adequately anticoagulated one year after CA for AF. Paroxysmal AF or freedom from AF is significantly associated with discontinuation of OAC.

Schlüsselwörter

Vorhofflimmern - Katheterablation - Antikoagulation - Leitlinien - CHA₂DS₂-VASc-Score

Keywords

atrial fibrillation - catheter ablation - anticoagulation - guidelines - CHA₂DS₂-VASc-Score

• Literatur

• 1 Arya A, Piorkowski C, Sommer P et al. Clinical implications of various follow up strategies after catheter ablation of atrial fibrillation. Pacing Clin Electrophysiol 2007; 30: 458-462
• 2 Bunch TJ, Crandall BG, Weiss JP et al. Warfarin is not needed in low-risk patients following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol 2009; 20: 988-993
• 3 Calkins H, Kuck KH, Cappato R et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 2012; 14: 528-606
• 4 Camm AJ, Lip GY, De Caterina R et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation – developed with the special contribution of the European Heart Rhythm Association. Europace 2012; 14: 1385-1413
• 5 Chao TF, Lin YJ, Tsao HM et al. CHADS(2) and CHA(2)DS(2)-VASc scores in the prediction of clinical outcomes in patients with atrial fibrillation after catheter ablation. J Am Coll Cardiol 2011; 58: 2380-2385
• 6 European Heart Rhythm Association (EHRA), European Association for Cardio-Thoracic Surgery (EACTS). Camm AJ et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace 2010; 12: 1360-1420
• 7 Farmakis D, Pipilis A, Antoniou A et al. Clinical profile and therapeutic management of patients with atrial fibrillation in Greece: results from the Registry of Atrial Fibrillation to Investigate New Guidelines (RAFTING). Hellenic J Cardio 2013; 54: 368-375
• 8 Healey JS, Connolly SJ, Gold MR et al. Subclinical atrial fibrillation and the risk of stroke. The N Engl J Med 2012; 366: 120-129
• 9 Hindricks G, Piorkowski C, Tanner H et al. Perception of atrial fibrillation before and after radiofrequency catheter ablation: relevance of asymptomatic arrhythmia recurrence. Circulation 2005; 112: 307-313
• 10 Hylek EM, Go AS, Chang Y et al. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med 2003; 349: 1019-1026
• 11 January CT, Wann LS, Alpert JS et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014;
• 12 Nieuwlaat R, Capucci A, Lip GY et al. Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation. Eur Heart J 2006; 27: 3018-3026
• 13 Oral H, Chugh A, Ozaydin M et al. Risk of thromboembolic events after percutaneous left atrial radiofrequency ablation of atrial fibrillation. Circulation 2006; 114: 759-765
• 14 Oral H, Knight BP, Tada H et al. Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation 2002; 105: 1077-1081
• 15 Pipilis A, Farmakis D, Kaliambakos S et al. Anticoagulant therapy is prescribed less often in paroxysmal atrial fibrillation regardless of thromboembolic risk: Results from the Registry of Atrial Fibrillation To Investigate New Guidelines (RAFTING). Int J Cardiol 2014; 175: 569-570
• 16 Reynolds MR, Shah J, Essebag V et al. Patterns and predictors of warfarin use in patients with new-onset atrial fibrillation from the FRACTAL Registry. Am J Cardiol 2006; 97: 538-543
• 17 Saad EB, d'Avila A, Costa IP et al. Very low risk of thromboembolic events in patients undergoing successful catheter ablation of atrial fibrillation with a CHADS2 score </=3: a long-term outcome study. Circ Arrhythm Electrophysiol 2011; 4: 615-621
• 18 Themistoclakis S, Corrado A, Marchlinski FE et al. The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation. J Am Coll Cardio 2010; 55: 735-743
• 19 Tzou WS, Marchlinski FE, Zado ES et al. Long-term outcome after successful catheter ablation of atrial fibrillation. Circ Arrhythm Electrophysiol 2010; 3: 237-242
• 20 Verma A, Champagne J, Sapp J et al. Discerning the incidence of symptomatic and asymptomatic episodes of atrial fibrillation before and after catheter ablation (DISCERN AF): a prospective, multicenter study. JAMA Intern Med 2013; 173: 149-156
• 21 Weerasooriya R, Khairy P, Litalien J et al. Catheter ablation for atrial fibrillation: are results maintained at 5 years of follow-up?. J Am Coll Cardiol 2011; 57: 160-166