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2018 AF Symposium: A Friendly Debate “Can Anticoagulants Be Stopped After AF Ablation?”

by Steve Ryan

An especially interesting presentation at the 2018 AF Symposium was a friendly debate between Dr. Francis Marchlinski of the Un. of Pennsylvania Health Center in Philadelphia, PA and Dr. Elaine M. Hylek of Boston Un. Medical Center. This is a topic of great interest to A-Fib patients:

 “Can Anticoagulants be Stopped after AF Ablation?”

• Dr. Francis Marchlinski took the “Yes” position (anticoagulation can be stopped).
• Dr. Elaine M. Hylek took the “No” position (anticoagulation should not be stopped).

Though labeled a friendly “debate”, there was no debate winner or loser; It was a more dramatic way of presenting different views on anticoagulation and ablation.

Dr. Marchlinski described what he hears from patients, that they don’t want to be on anticoagulants. They ask me, “Doc, would you use anticoagulation if I didn’t have A-Fib? Because I’m telling you, I’m not having Atrial Fibrillation.”

In general, he said patients don’t want to have to take anticoagulants, especially after a successful ablation when they are A-Fib free. They are reluctant to take anticoagulation in the absence of EKG and other methods of monitoring when combined with no symptoms of A-Fib.

Note: Usually the first person in a debate is at a disadvantage. But Dr. Marchlinski instead anticipated what points Dr. Hylek would make and addressed them in his presentation.

Pro: Stop Anticoagulation after Ablation

Francis Marchlinski, MD

Dr. Marchlinski spoke in favor of stopping anticoagulation. He anticipated several points that Dr. Hylek might argue, then added his response. ‘Dr. Hylek might say’…

• …there are no randomized studies proving that anticoagulation can be safely stopped after a successful ablation. True, he said. (Later in the debate, he and Dr. Hylek both agreed on this point.)

• …there are some observational studies and registries that indicate there is a high risk of stroke when stopping anticoagulation after an ablation. He countered by pointing out that many of these studies included patients who still had A-Fib after their ablation.

• …every ablation has recurrences of A-Fib. He said, not in his practice. And in general, this is simply not true. A-Fib ablation has improved significantly over the years.

• …recurrences can be asymptomatic. True, so he trains his patients to use pulse assessment and other methods to check for heartbeat irregularities, and if found, to get in touch with his office. He pointed out that the field of monitoring and the increased variety of monitors available makes it less likely that long periods of A-Fib will go unnoticed.

• …A-Fib is a marker for more serious heart remodeling problems like cardiomyopathy, enlarged left atrium, inadequate left atrial contraction, etc. and therefore patients should be on anticoagulants. He countered by describing how carefully he and most other EPs examine a patient’s heart before, during and after an ablation. If any patient has any serious underlying heart problem, they are monitored life-long and are often on anticoagulants for life.

• He described using NOACs as a pill-in-the-pocket in certain cases when a patient has a recurrence, so that the patient doesn’t have to be on anticoagulants all the time.

• Bleeding risk is still significant, he noted, although the NOACs in general tested better than warfarin.

Con: Continue Anticoagulation after Ablation

Elaine M Hylek, MD

Dr. Hylek stressed that anticoagulation should not be stopped after an ablation. Her main points were:

• There is no way to reliably predict recurrences of A-Fib after an ablation. She encouraged the development of a predictive model.

• Pulse assessment is not reliable. Too many patients can’t recognize ectopic beats, for example.

• She discussed how serious heart remodeling problems can underlie A-Fib, and that these can cause strokes.

• Current monitoring is variable and unreliable. We need larger studies to improve this field.

• She cited a study of what she called “wake up strokes” where a patient wakes up in the morning and has suffered a stroke. By then it’s usually too late to be of much help. She indicated that 25% of strokes are these “wake up strokes.” She stressed how EPs need to do sleep apnea studies on A-Fib patients. [Many centers in the U.S. now automatically send anyone with A-Fib to a sleep apnea center for a study.]

Note: Though labeled a friendly “debate”, there was no debate winner or loser; It was just a more dramatic way of presenting different views on taking anticoagulants and catheter ablation.
Editor’s Comments:
(Just between you and me, I think Dr. Marchlinski won the debate.)
Patients don’t want to take anticoagulants after a successful ablation: The most telling point Dr. Marchlinski made was describing how most patients don’t want to take anticoagulants, especially after a successful ablation. In fact, one of the reasons patients have an ablation is to no longer have to take anticoagulants (and all the other A-Fib drugs which have so many bad side effects and long-term consequences.)
Recurrences are decreasing as ablation improves: With the use of contact force sensor catheters, Cryo and Laser Balloon ablation, advanced mapping techniques, etc., recurrence of A-Fib after an ablation has decreased significantly.
A-Fib patients aren’t dumb and can learn to take their pulse: Most patients are smart enough to take their own pulse or use today’s portable DIY monitors to tell if they are in A-Fib.
Anticoagulants are high risk drugs: Dr. Hylek didn’t discuss the dangers or acknowledge that anticoagulants are high risk drugs which can cause bleeding problems. For more about how NOACs dosage levels may also need to monitored, see the posted article: New Oral Anticoagulants Can Require Careful Dosing Too on the AFA discussion page.

Disclosures: Dr. Hylek lists in her disclosure statement extensive ties to the pharmaceutical industry; Dr. Marchlinski lists ties to medical device makers.

If you find any errors on this page, email us. Y Last updated: Wednesday, February 21, 2018

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