SPC365

Long-term risk of major cardiovascular events after cavotricuspid isthmus ablation: when and in whom to discontinue oral anticoagulation?

Session: CO 03 - Flutter/atrial fibrilation
Speaker: Joana Brito

Congress: CPC 2021
Topic: C. Arrhythmias and Device Therapy
Theme: 05. Atrial Fibrillation
Subtheme: 05.7 Atrial Fibrillation - Prevention
Session Type: Comunicações Orais
FP Number: ---
Authors: Joana Brito; Tiago Rodrigues; Pedro Silverio Antonio; Beatriz Silva; Pedro Alves da Silva; Nelson Cunha; Ana Bernardes; Luis Carpinteiro; Gustavo Lima da Silva; Nuno Cortez-Dias; João de Sousa; Fausto j. Pinto

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><strong><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">Introduction</span></span></span></strong><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">&nbsp;Cavotricuspid isthmus ablation (CTA) is the 1st-line therapy to accomplish rhythm control in patients (pts)&nbsp;with typical atrial flutter (AFL). While AF&nbsp;embolic risk&nbsp;is well established, data regarding AFL and formal recommendations for long-term anticoagulation after CTA in pts with isolated AFL.&nbsp;</span></span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><strong><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">Purpose</span></span></span></strong><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">&nbsp;To determine the risk of major adverse cardiovascular events (MACE) after CTA and to compared it with the presence of concomitant AF,&nbsp;concomitantly performing pulmonary vein isolation (PVI) and persistence on long-term oral anticoagulation (OAC).</span></span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><strong><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">Methods&nbsp;</span></span></span></strong><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">Single-center retrospective study of&nbsp;pts&nbsp;submitted to CTA between 2015 to 2019, comprising three groups: I &ndash; pts with lone AFL; II &ndash; patients with AFL and prior AF submitted to CTA only; and III &ndash; pts with AFL and prior AF submitted to IVP and CTA. Clinical records were analyzed to determine the occurrence of MACE during the long-term follow up (FUP), defined as death (cardiovascular or unknown cause), stroke, clinically relevant bleed or hospitalization due to heart failure or arrhythmic events. Long-term OAC was defined as its persistence over 18 months after CTA. Analysis was performed with Kaplan Meier and Cox regression.</span></span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><strong><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">Results</span></span></span></strong><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">&nbsp;476 pts (66&plusmn;12 years, 80% males) underwent CTA: group I &ndash; 284 pts (60%), II &ndash; 109 pts (23%) and III &ndash; 83 pts (17%). Baseline characteristics were similar between groups, except for age with group I pts being older (68&plusmn;12, 67&plusmn;11, 61&plusmn;11, p&lt;0.03). The mean baseline CHA<sub>2</sub>DS<sub>2</sub>VASc was 2.3&plusmn;1.5 and the median post-CTA follow-up was 2.8 year. The 1, 3 and 5years MACE risk was 6.8%, 21.1% and 32.1%, respectively and did not differ significantly between groups. OAC was suspended on the long-term in 105 pts (23%), at a mean of 241 days post-CTA. Suspension of OAC was associated with lower MACE risk (HR: 0.26, 95%CI 0.12-0.56, p 0.001). This effect was independent of age and CHA<sub>2</sub>DS<sub>2</sub>VASc, also a significant prognostic predictor (HR1.28, 95%CI 1.08-1.53, p0.005). The prognostic benefit of OAC suspension was driven by the group I and was not verified in pts with concomitant AF. In group I, withdraw of anticoagulation (56 pts 27.3%) was associated with 70% relative risk reduction in the 5year MACE risk (16.1% vs 42.9%, HR0.30, 95%CI 0.13-0.69, p0.005). In group I, OAC was suspended in younger pts (65&plusmn;11 vs. 69&plusmn;12, p=0.002), lower CHA<sub>2</sub>DS<sub>2</sub>VASc (1.9&plusmn;1.6 vs. 2.7&plusmn;1.4, p&lt;0.001) and lessen cerebrovascular disease (1.4% vs. 8.1%, p0.036), heart failure (14.1% vs. 37.9%, p0.001), ischemic cardiomyopathy (8.5% vs 18.8%, p 0.04) and hypertension (60.6% vs. 75.3%, p 0.019).</span></span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><strong><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">Conclusion</span></span></span></strong><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">&nbsp;In pts with AFL submitted to CTA, long-term risk of MACE was high, even in those without concomitant AF. Among pts with prior AF documented with typical AFL submitted to CTA, the long-term prognosis was similar. In pts with lone AFL submitted to successful CTA, it may be reasonable to suspend OAC within 18 months provided that concomitant AF is carefully excluded during FUP.&nbsp;</span></span></span></span></span></p>