Updated with a comment from John Mandrola– As dabigatran becomes more widely used in atrial fibrillation (AF) patients, electrophysiologists are now trying to figure out how to handle anticoagulation in patients taking dabigatran (Pradaxa) for whom AF ablation is planned. In a new study published in the Journal of the American College of Cardiology, Dhanunjaya Lakkireddy and colleagues report on a multicenter, observational study of 290 patients who underwent an AF ablation procedure. Half the patients were taking periprocedural dabigatran and half were matched controls taking warfarin.
There were significantly more thromboembolic and bleeding complications in the dabigatran group than in the warfarin group:
- Thromboembolic complications: 3 in the dabigatran group versus 0 in the warfarin group (p=0.25)
- Major bleeding complicatons: 9 versus 1 (p=0.019)
- Composite of bleeding and thromboembolic complications: 16% vs. 6% (p = 0.009)
In a multivariate analysis, dabigatran was an independent predictor of bleeding or thromboembolic complications (OR 2.76, CI 1.22 – 6.25; p = 0.01).
In an editorial comment, Bradley Knight writes that the study “at first… appears to suggest that dabigatran has no role periprocedurally in patients undergoing AF ablation.” Although “AF ablation should not be performed on nearly uninterrupted dabigatran, as it was used in this study,” Knight preserves hope for “other approaches that capitalize on the advantages of the new oral anticoagulants.”
Electrophysiologist John Mandrola told CardioBrief that “the concern about periprocedural anticoagulation is very important.” He admits to favoring warfarin to avoid any interruption of anticoagulation but points out that in “the real world, switching back and forth between blood thinners confers some risk too. So I don’t insist that patients on dabigatran change to warfarin, especially if I think they are actually taking the drug and are at low-risk for clots.”