The multicenter STROKE-VT trial, published in JACC: Clinical Electrophysiology, investigated differences in cerebrovascular events (CVE) between post-procedure use of DOACs or ASA in patients undergoing LVA radiofrequency ablation (LVA-RFA).
Dr. Dhanunjaya Lakkireddy of the Kansas City Heart Rhythm Institute and Research Foundation in Overland Park and colleagues randomized 246 patients (mean age, about 60; about 82% men) scheduled for LVA-RFA to DOACs or ASA. Baseline and ablation characteristics were mostly the same between the groups.
The primary endpoint was the incidence of stroke or transient ischemic attack, or MRI-detected asymptomatic cerebrovascular events (ACE) at 24 hours and 30 days follow-up.
The team found that post-procedure CVEs were lower in the DOAC arm (stroke, 0% vs. 6.5%, and TIA, 4.9% vs. 18%).
Further, the ASA group had higher MRI-detected ACE at 24 hours (23% vs. 12%) and 30 days (18% vs. 6.5%).
Rates of acute procedure-related complications and in-hospital mortality were similar between the groups.
After adjustment, compared to DOAC use, the odds ratio for a post-procedure CVE with aspirin was 12.6; for MRI-detected asymptomatic CVE at 24 hours, 2.15; and for an MRI-detected asymptomatic CVE at 30 days, 3.48.
Dr. Usha Tedrow of Brigham and Women's Hospital in Boston, coauthor of a related editorial, told Reuters Health by email, "Despite important technological advances in catheter ablation, there have been relatively few randomized trials of therapies and no randomized trials of post-procedure anticoagulation."
"The most recent guidelines for management of anticoagulation after VT catheter ablation have been based on consensus opinion and observational trials dating back over a decade," she said. "Older studies predate the advent of DOACs (for this indication)."
"STROKE-VT is the first-ever piece of rigorous evidence for stroke-risk reduction after VT catheter ablation," she noted. "There are certainly some VT patients who cannot take DOACs for clinical reasons or in whom the ablation approach (epicardial access) may preclude the use of a DOAC post-procedure. However, I think (all) VT ablationists should ask themselves whether their patient is a candidate for DOAC after VT catheter ablation because of this evidence."
"I am confident that in the next iteration of VT catheter ablation guidelines, these results will appear prominently," she concluded.
Dr. Raffaele Corbisiero, Chair, Electrophysiology Services at Deborah Heart and Lung Center in Browns Mills, New Jersey, also commented on the study by email. "Although rare, a stroke can be a devastating complication for any patient, so minimizing that risk is always paramount."
"This study showed you could reduce the 24-hour and 30-day risks by almost half with OAC compared to aspirin," he said. "This is how we have been managing our ablation patients for some time at Deborah, barring any contraindication to OAC. I think it also demonstrates how aspirin continues to fall out of favor with many who perform ablation procedures on the arterial side post- intervention. This should be standard of care moving forward."
Dr. Lakkireddy did not respond to requests for a comment.
SOURCE: https://bit.ly/3fox02E and https://bit.ly/3lnSLmZ JACC: Clinical Electrophysiology, online July 29, 2021.
By Marilynn Larkin
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