Background: After atrial fibrillation (AF) ablation, OAC is recommended if CHA₂DS₂-VASc score is ≥1 in men; ≥2 in women. However, patients (pts) are often reluctant to take daily OAC if no AF. We described pts with high CHA₂DS₂-VASc score who used direct OACs (DOACs) “as needed - PRN ” guided by pulse monitoring to detect AF post AF ablation.
Objective: To describe the longer term follow up in this group of pts to assess for continued safety and efficacy.
Methods: We studied 99 patients (84% male, age 64 ± 8 years, CHA₂DS₂-VASc median 2, range 1-6) with pulse assessment twice daily and no AF on ECG monitoring after AF ablation. Patients started DOAC if with pulse irregularity/AF and continue for minimum of 2 to 4 weeks with efforts to document rhythm. Daily DOAC was typically restarted if recurrent AF episodes (>1/3mos). We previously reported results over 30 ± 14 mos (total 244 patient-yrs) and now report longer-term results (52 ± 22 mos, total 421 patient-yrs) in same cohort.
Results: In initial report: 22 patients (22%) transitioned to daily DOAC and 14 (14%) used PRN DOACs but did not transition to daily use. There was only one thromboembolic event in pt without AF on all monitoring (0.4%/yr of follow-up) and one bleeding event (epistaxis).
In longer-term follow up, 44/99 pts (44%) have not taken DOACs and continue to monitor pulse daily. An additional 13 pts transitioned to daily DOAC for non-compliance with pulse assessment (1), frequent ectopy precluding accurate pulse assessment (2), increase CHA₂DS₂-VASc to 6 (1), and AF episodes (9). Of the 22 who previously restarted daily DOACs, 4 (18%) resumed PRN use after 6 -12 mos without AF. Five additional pts used PRN DOAC 1-3 times. There were no further thromboembolic events (0.2%/yr), and 2 with minor bleeding, hematuria (1) and epistaxis (1), which resolved with interruption of OAC.
Conclusion: In longer term follow-up, PRN DOACs when AF is detected with pulse monitoring was an effective and safe strategy in maintaining low risk of stroke without increased bleeding in pts with no or rare AF after ablation. Follow-up is required to confirm compliance and identify AF recurrence and need to restart daily DOAC which can be anticipated in ~1/3 of patients in long term follow-up.