From the Guidelines
The incidence of stroke after atrial fibrillation ablation is a significant concern, and thus, anticoagulation therapy is crucial to prevent thromboembolic complications around ablation procedures. The risk of stroke is increased around the time of the procedure, highlighting the importance of continuous anticoagulation therapy, even in patients without stroke risk factors 1.
Key Considerations
- The European Heart Rhythm Association recommends continuation of oral anticoagulation (OAC) therapy during ablation procedures, with a target INR of 2.0-3.0 for patients on vitamin K antagonists (VKAs) 1.
- The use of non-vitamin K antagonist oral anticoagulants (NOACs) peri-ablation is limited, and initial reports suggest a slightly increased stroke risk, although the exact relative risk is unknown 1.
- Bridging with heparin is not recommended, and initiation of anticoagulation with NOACs shortly after the ablation procedure seems reasonable for patients taken off OAC before the procedure 1.
Recommendations
- Patients should receive anticoagulation therapy before, during, and after ablation to minimize stroke risk.
- The choice of anticoagulant and duration of therapy should be individualized based on the patient's stroke risk factors and other clinical considerations.
- Continuous anticoagulation therapy with a VKA or NOAC is recommended for at least 2-3 months post-procedure, regardless of the CHA₂DS₂-VASc score.
Clinical Implications
- The incidence of stroke after atrial fibrillation ablation can be minimized with appropriate anticoagulation therapy.
- Patients should be closely monitored for signs and symptoms of stroke and thromboembolic complications after the procedure.
- The benefits of anticoagulation therapy in preventing stroke outweigh the risks of bleeding complications in most patients.
From the Research
Incidence of Stroke after Atrial Fibrillation Ablation
- The incidence of stroke after atrial fibrillation ablation is relatively low, with studies reporting rates ranging from 0.2% to 0.61% per patient-year 2, 3.
- A study of 1,990 patients who underwent atrial fibrillation ablation found that 16 strokes or transient ischemic attacks (TIAs) occurred, resulting in a stroke rate of 0.2% per patient-year 2.
- Another study of 24,244 patients found that the periprocedural stroke or TIA rate was 0.5% in the ablation group and 0.3% in the cardioversion group 4.
- A population-based study of 6,207 patients who underwent atrial fibrillation ablation found that the 30-day mortality and stroke rates were 0.39% and 0.61%, respectively 3.
Risk Factors for Stroke after Atrial Fibrillation Ablation
- Prior stroke or transient ischemic attack (TIA) is a significant predictor of stroke after atrial fibrillation ablation 2, 3, 5.
- Age ≥80 years and heart failure are also independent predictors of death after atrial fibrillation ablation 3.
- The presence of atrial fibrillation after ablation is a risk factor for future stroke 5.
- The CHADS2 score is used to assess the risk of stroke in patients with atrial fibrillation, and studies have found that atrial fibrillation ablation can reduce the risk of stroke in all CHADS2 risk profiles 6.
Comparison of Stroke Risk after Atrial Fibrillation Ablation and Cardioversion
- A study found that the periprocedural stroke or TIA rate was higher in the ablation group than in the cardioversion group, but the long-term stroke rate was lower in the ablation group 4.
- Another study found that atrial fibrillation ablation patients had a lower long-term risk of stroke compared to patients without ablation, and similar long-term risks of stroke compared to patients with no history of atrial fibrillation 6.