AF Symposium 2015
Preventing TIA/Stroke During an Ablation
One of the reasons for getting a catheter ablation is to lower the risk of an A-Fib stroke and protect the brain. So to have a TIA/stroke during or after an ablation is, as Dr. Luigi Di Biase of the Albert Einstein College of Medicine, Bronx, NY, states “I think the worst complication ever in the field.” That’s why patients are put on anticoagulants like warfarin before and after an ablation and heperin during the actual ablation.
Most complication statistics after an ablation are of paroxysmal A-Fib patients. But Dr. Di Biase pointed out that ablations for persistent and long-term persistent often involve more tissue burns and consequently more risk of TIAs/stroke. In these cases periprocedural anticoagulation is even more important.
Uninterrupted Xarelto & Eliquis in Ablations as Effective and Safe as Warfarin, But Not Pradaxa
Dr. Di Biase discussed the COMPARE trial which showed the superiority of a strategy of uninterrupted warfarin anticoagulation both before and after an ablation in reducing TIAs/stroke and “silent” lesions. (“Silent” cerebral ischemia are lesions that show up on an MRI but don’t seem to have any effect and often go away on their own. But doctors still worry about and don’t know the long-term effects of these silent brain tissue disruptions.) He pointed out that doctors should still use heperin during the actual ablation, as most centers do.
But what about the NOACs (Novel Oral Anticoagulants)? Are they as effective as warfarin? “We have preliminary data showing that uninterrupted strategies with rivaroxaban (Xarelto) and apixaban (Eliquis) dramatically reduce the amount of silent thromboembolic lesions as well, and are as safe as warfarin in terms of TIA and stroke.” He wasn’t able to produce these results with Pradaxa.
Still No Reversal Agents for Xarelto & Eliquis, But Change is Coming
With the use of both warfarin and heperin, there is an increased risk of bleeding. Dr. Di Biase described how at his center they use fresh frozen plasma for bleeding management of warfarin and heperin bleeds. But there are still no direct reversal agents for the NOACs. Dr. DiBiase seemed confident that a new reversal agent for apixaban and rivaroxaban looks very promising “to completely reverse the effects of these two drugs in less than four minutes.”
I usually don’t discuss drugs until they’ve actually been approved by the FDA. But a reversal agent for Xarelto and Eliquis does seem to be on FDA fast track for approval and would certainly be a most welcome development for A-Fib patients. It might even work better than the current reversal agents for warfarin.
(Added August, 15, 2015): An experimental drug idarucizumad has show positive results as a reversal agent for Pradaxa (dabigatran). In a new study of 90 patients who had uncontrolled bleeding with Pradaxa, idarucizumad stopped this bleeding within minutes for all 90 patients. No serious side effects were reported. FDA approval is pending.
We shouldn’t blame the FDA for approving the NOACs without any reversal process or remedy to stop bleeding. There has been an incredible need for new, different anticoagulants for nearly 40 years. It may have been worse if the FDA had kept the NOACs off of the market.
Marzo, Kevin. Blood thinner Antidote. Bottom Line Health, Volume 29, Number 9, September 2015, p. 1.
Mundell, E.J.. Drug May Be Antidote to Bleeding Tied to Blood Thinner Pradaxa. Medline Plus. Monday, June 22, 2015. http://www.nlm.nih.gov/medlineplus/news/fullstory_153206.html
Last updated: Saturday, August 15, 2015