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Novel oral anticoagulants in the electrophysiology lab: are we really ready to forget warfarin?

This editorial refers to ‘Novel oral anticoagulants in a real-world cohort of patients undergoing catheter ablation of atrial fibrillation’ by C. Eitel et al ., on page 1587. 

Atrial fibrillation (AF) is the most common arrhythmia, affecting over 6 million people in Europe. Subjects suffering from this arrhythmia have a five-fold higher risk of stroke than those in stable sinus rhythm, and anticoagulation with vitamin K antagonists has proven able to reduce this risk by about 60%.

Recently, new oral anticoagulants (NOACs) have been introduced in the clinical practice and have proven non-inferior to warfarin in preventing thromboembolic risk in patients affected by non-valvular AF.1,2 Moreover, NOACs significantly reduce the risk of cerebral haemorrhage, act rapidly, and are easier to administer, considering that monitoring of the international normalized ratio (INR) is not required and a lower interaction with food and other drugs is described. However, these drugs display the limitation to have no antidote and the difficulty to assess patient compliance.

In the last 10 years, catheter ablation has become an effective therapeutic option for treatment of symptomatic and drug-refractory AF. Nevertheless, this therapy may be associated with complications, mainly thromboembolic events, cardiac tamponade, and vascular complications.1,3 Over the years, various antithrombotic treatments for use either during or after the procedure have been proposed to maximize protection against thromboembolic events and to reduce the risk of bleeding. However, the lack of prospective, randomized, large-scale studies has led to the emergence of different approaches, which are largely based on the operator's experience. There is a general agreement on the need to anticoagulate the patient in the period prior to the procedure following the same recommendations that pertain to AF cardioversion. The most widely adopted strategy is discontinuation of warfarin and bridging with low-molecular-weight heparin (LMWH) or …