ESC Congress 2017 In Review – Focus on Arrhythmias - 9A

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Sponsored Session Highlights
Advances in the Management of
Atrial Fibrillation
Speakers at the European Society of Cardiology 2017
Congress discussed recent developments that offer new
approaches to improving management of patients with
atrial fibrillation (AF). These include advances in use of
non-vitamin K antagonist oral anticoagulants (NOACs)
in AF based on data from pivotal clinical trials, as well
as recently updated consensus recommendations that
will help guide clinicians' treatment decision-making in
patients with AF who need ablation or percutaneous
coronary intervention (PCI).
Managing Antithrombotic Therapy in AF
Patients Undergoing Ablation
Choosing an anticoagulation strategy for patients undergoing AF ablation can challenge physicians because of the
need to balance the risks of thromboembolism and periprocedural bleeding. However, periprocedural oral anticoagulant (OAC) use is a rapidly evolving field, said Gregory Y.
H. Lip, MD, University of Birmingham, United Kingdom, and
emerging data continue to guide clinical-decision pathways.
Stephan Willems, MD, University Hospital HamburgEppendorf, Hamburg, Germany, highlighted recent data
from the RE-CIRCUIT trial.1 This assessed the safety
of uninterrupted treatment with dabigatran (150 mg
BID) versus warfarin (target INR, 2.0 to 3.0) in patients
undergoing AF ablation, and provided important information on the superior safety profile of uninterrupted
dabigatran treatment.
The risk of major bleeding during and after ablation
was significantly lower in patients receiving dabigatran than warfarin (Figure 1). There was no difference
between the 2 groups in the incidence of minor bleeding events, and thromboembolic events were rare, with
only 1 occurring in the warfarin group. No fatal events
occurred in either of the 2 groups during the procedure.

Patients with ISTH Major Bleeding (%)

Figure 1. Risk of Major Bleeding in RE-CIRCUIT
8
6

Absolute Risk
Difference -5.3%
(P = .001)

Relative Risk
Reduction 77.2%

n=5

Dabigatran
150 mg BID
(n = 317)

n = 22

Warfarin
(n = 318)

Source: Calkins H et al. N Engl J Med. 2017; 376:1627-1636. doi:10.1056/NEJMoa1701005.

According to Hugh Calkins, MD, Johns Hopkins
Medical Institutions, Baltimore, USA, the introduction of
idarucizumab-a specific reversal agent for dabigatran-has
also changed how some clinicians manage patients on
OACs. Dabigatran is the only NOAC with a specific reversal agent; this offers an advantage if rapid reversal of the
anticoagulant is needed. The REVERSE-AD trial showed
that idarucizumab provided immediate, complete, and
sustained reversal of dabigatran anticoagulation in
patients who either had uncontrolled bleeding or who
needed emergency surgery.2
The availability of this reversal agent could motivate
clinicians to adopt uninterrupted dabigatran as the preferred anticoagulation strategy in patients undergoing
AF ablation, Dr Calkins noted. The 2017 HRS/EHRA/
ECAS/APHRS/SOLAECE expert consensus statement,
gives a class 1, level of evidence A recommendation for
performing AF ablation on uninterrupted warfarin or
dabigatran, he stated.3
Overall, NOACs-including dabigatran-have changed
clinical practice in terms of AF ablation and its associated risks, concluded Richard Schilling, MD, Barts
Hospital, London, United Kingdom. He noted that studies have increasingly shown a declining risk of thromboembolism with ablation, which is beneficial for patients.
And although cardiac tamponade is the most feared
complication of AF ablation, Dr Schilling indicated that
it is treatable and is associated with a more favourable
prognosis than that of a severe stroke.
Managing Antithrombotic Therapy in AF
Patients Undergoing PCI
Patients with both coronary artery disease (CAD) and
AF who undergo PCI also represent a difficult group
for clinicians to manage, stated Georg Nickenig, MD,
University of Bonn, Germany. Not only do these patients
take aspirin to prevent atherothrombotic events, but
they also need a P2Y12 inhibitor such as clopidogrel
after stent placement, as well as an OAC to reduce the
risk of stroke. However, this triple therapy leaves these
individuals at high risk for bleeding events.
In addition to preventing atherothrombotic events, Dr
Nickenig indicated that a low bleeding rate is another
key treatment target in these patients. He shared data
from the WOEST study, showing that dual therapy using
a vitamin K antagonist (VKA) and clopidogrel reduces
bleeding risk compared with triple therapy using a VKA,
clopidogrel, and aspirin.4 Dr Nickenig added that the
results of this and other studies5-7 have contributed to
newly updated consensus recommendations on dual
antiplatelet therapy in CAD and AF.
The guidelines recommend that if ischaemic risk is
more prevalent, clinicians use triple therapy for up to 6
months, followed by dual therapy to 12 months. However,

This peer-reviewed article was based on scientific-clinical content presented at the ESC (European Society of Cardiology) Congress 2017. The content of this article
was entirely developed by Content Ed Net Medicom, and the opinions expressed herein do not necessarily represent those of the European Society of Cardiology, nor
of Boehringer Ingelheim, GmbH. The development of this article was supported by Boehringer Ingelheim, GmbH. This material is intended for educational purposes.

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