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Salt Lake City, Utah: A new study (1) comparing the stroke risk after atrial fibrillation(AF) ablation to the risk in AF patients not referred for ablation demonstrated that there is reduced risk after AF ablation irrespective of age and CHADS2 score. Furthermore the risk after AF ablation was similar to stroke risk in non-AF patients with similar CHADS2 risk profile.
Current guidelines state that decision regarding anticoagulation after AF ablation should be based on CHADS2 score. Stroke risk after AF ablation is lower compared to the risk in AF patients on warfarin. This may be due to selection bias with more healthy patients being selected for AF ablation or due to beneficial atrial remodeling and decreased arrhythmia burden after AF ablation. This study sought to determine whether decreased stroke risk extended across different CHADS2 risk groups. This was multicenter observational study evaluating the incidence of stroke in three patient cohorts: (i) AF ablation group (ii) AF group in whom ablation was not performed and (iii) non AF group. The AF ablation patients were identified from prospective AF registry. Control groups i.e., AF patients with no ablation and non-AF group consisted of patients matched by age and sex in 4:1 ratio to AF ablation cohort. AF history was determined by clinic notes, ICD codes and EKG database. Patients in all three groups included only those who were followed for at least 3 years. Primary outcome of interest i.e., stroke or cerebro-vascular accident was determined by using ICD-9 codes.
The study population included 37,908 patients with 4212 patients in AF ablation group, 16,848 AF patients in whom ablation was not performed and third group consisting non-AF patients. Incidence of stroke at one year was 2.4%. Event rate was higher in AF patients without ablation (3.5%) compared to AF ablation (1.4%) and non-AF patients (1.4%) (p-trend <0.0001). There was no increased risk of stroke in AF ablation group when compared to non-AF cohort after univariate(OR 1.01, p=0.95) and multivariate adjustment(OR =0.95, p=0.74). There was an increased risk of stroke in AF patients without ablation versus AF ablation patients across all age groups (< 60 yrs: HR 0.38, p<0.0001, 60-69: HR 0.59, p=0.005, 70-79:HR 0.50,p<0.0001) except those > 80 years ( HR 0.72, p =0.17). There was increased risk of stroke in AF patients with no ablation compared to other groups across all CHADS2 scores.
This study showed that the risk of stroke in patients undergoing AF ablation is similar to patients without AF across different age groups as well as CHADS2 risk profile. The authors propose multiple reasons for decrease in stroke risk after AF ablation: 1) decreased AF burden and favorable electrical and structural atrial remodeling 2) decreased dependency on arrhythmia medications and 3) more aggressive management of risk factors in post ablation patients. Conversely, reduced stroke risk in catheter ablation patients may be due to selection bias as healthy patients are more likely to undergo ablation.
Reference: 1. Bunch TJ, May HT, Bair TL, Weiss JP, Crandall BG, Osborn JS, et al. Atrial fibrillation ablation patients have long-term stroke rates similar to patients without atrial fibrillation regardless of CHADS2 score. Heart rhythm : the official journal of the Heart Rhythm Society. 2013;10(9):1272-7. Epub 2013/07/10. doi: 10.1016/j.hrthm.2013.07.002. PubMed PMID: 23835257.
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