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/></a></div><div class="bkr_bib"><h1 id="_NBK571346_"><span itemprop="name">Discontinuing anticoagulation in people whose atrial fibrillation has resolved</span></h1><div class="subtitle">Atrial fibrillation: diagnosis and management</div><p><b>Evidence review H</b></p><p><i>NICE Guideline, No. 196</i></p><p class="contrib-group"><h4>Authors</h4><span itemprop="author">National Guideline Centre (UK)</span>.</p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2021 Apr</span>.</div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2021.</div></div><div class="bkr_clear"></div></div><div id="niceng196er7.s1"><h2 id="_niceng196er7_s1_">1. Discontinuing anticoagulation in people whose atrial fibrillation has resolved</h2><div id="niceng196er7.s1.1"><h3>1.1. Review question: What is the clinical and cost-effectiveness of discontinuing anticoagulation in people whose atrial fibrillation has resolved?</h3></div><div id="niceng196er7.s1.2"><h3>1.2. Introduction</h3><p>As part of Atrial Fibrillation (AF) treatment, some people will undergo an ablation or have cardiac surgery. The aim of these procedures is to stop AF and reduce and/or eliminate AF symptoms such as palpitations, dizziness and breathlessness. If the procedure is successful, the result means the AF is deemed resolved. What this means for the person with AF is that they no longer have detectable atrial fibrillation. The AF is classed as resolved when there is no longer have any evidence of any form of atrial fibrillation (usually this is confirmed by ECG or a period of monitoring). For those who had experienced symptoms, after the procedure, AF is seen as resolved if the person reports that they no longer experience any symptoms. This section will examine the clinical and cost effectiveness of discontinuing anticoagulation in people whose atrial fibrillation has resolved. This specifically relates to people who had a clinical reason/ indication for anticoagulation in terms of stroke risk (i.e. CHADVASC score ≥2) and are not low risk of stroke.</p></div><div id="niceng196er7.s1.3"><h3>1.3. PICO table</h3><p>For full details see the review protocol in <a href="#niceng196er7.appa">appendix A</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng196er7tab1"><a href="/books/NBK571346/table/niceng196er7.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng196er7tab1" rid-ob="figobniceng196er7tab1"><img class="small-thumb" src="/books/NBK571346/table/niceng196er7.tab1/?report=thumb" src-large="/books/NBK571346/table/niceng196er7.tab1/?report=previmg" alt="Table 1. PICO characteristics of review question." /></a><div class="icnblk_cntnt"><h4 id="niceng196er7.tab1"><a href="/books/NBK571346/table/niceng196er7.tab1/?report=objectonly" target="object" rid-ob="figobniceng196er7tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">PICO characteristics of review question. </p></div></div></div><div id="niceng196er7.s1.4"><h3>1.4. Methods and process</h3><p>This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual.<a class="bibr" href="#niceng196er7.ref42" rid="niceng196er7.ref42"><sup>42</sup></a> Methods specific to this review question are described in the review protocol in <a href="#niceng196er7.appa">appendix A</a>.</p><p>Declarations of interest were recorded according to NICE’s 2018 conflicts of interest policy.</p></div><div id="niceng196er7.s1.5"><h3>1.5. Clinical evidence</h3><div id="niceng196er7.s1.5.1"><h4>1.5.1. Included studies</h4><p>A search was initially conducted for randomised trials comparing outcomes between discontinuation and continuation of anticoagulants in people with resolved atrial fibrillation. No randomised trials were identified that matched the protocol for this review. Observational studies in the form of retrospective or prospective cohorts with adjustment for stroke and bleeding risk were therefore considered due to the absence of randomised trials, as pre-specified in the protocol for this review.</p><p>One observational study, a retrospective cohort study that compared outcomes between people switching from warfarin to aspirin (discontinuation of anticoagulants) and those continuing warfarin anticoagulation following ablation-induced resolution of atrial fibrillation, was included in the review;<a class="bibr" href="#niceng196er7.ref74" rid="niceng196er7.ref74"><sup>74</sup></a>thisissummarised in <a class="figpopup" href="/books/NBK571346/table/niceng196er7.tab2/?report=objectonly" target="object" rid-figpopup="figniceng196er7tab2" rid-ob="figobniceng196er7tab2">Table 2</a> below. Stroke and bleeding risk were not adjusted for in this study; however, the stroke and bleeding risks were similar at baseline for the two groups. Evidence from this study is summarised in the clinical evidence summary below (<a class="figpopup" href="/books/NBK571346/table/niceng196er7.tab3/?report=objectonly" target="object" rid-figpopup="figniceng196er7tab3" rid-ob="figobniceng196er7tab3">Table 3</a>).</p><p>See also the study selection flow chart in <a href="#niceng196er7.appc">appendix C</a>, study evidence tables in <a href="#niceng196er7.appd">appendix D</a>, forest plots in <a href="#niceng196er7.appe">appendix E</a> and GRADE tables in <a href="#niceng196er7.appf">appendix F</a>.</p></div><div id="niceng196er7.s1.5.2"><h4>1.5.2. Excluded studies</h4><p>See the excluded studies list in <a href="#niceng196er7.appi">appendix I</a>.</p></div><div id="niceng196er7.s1.5.3"><h4>1.5.3. Summary of clinical studies included in the evidence review</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng196er7tab2"><a href="/books/NBK571346/table/niceng196er7.tab2/?report=objectonly" target="object" title="Table 2" class="img_link icnblk_img figpopup" rid-figpopup="figniceng196er7tab2" rid-ob="figobniceng196er7tab2"><img class="small-thumb" src="/books/NBK571346/table/niceng196er7.tab2/?report=thumb" src-large="/books/NBK571346/table/niceng196er7.tab2/?report=previmg" alt="Table 2. Summary of studies included in the evidence review." /></a><div class="icnblk_cntnt"><h4 id="niceng196er7.tab2"><a href="/books/NBK571346/table/niceng196er7.tab2/?report=objectonly" target="object" rid-ob="figobniceng196er7tab2">Table 2</a></h4><p class="float-caption no_bottom_margin">Summary of studies included in the evidence review. </p></div></div><p>See <a href="#niceng196er7.appd">appendix D</a> for full evidence tables.</p></div><div id="niceng196er7.s1.5.4"><h4>1.5.4. Quality assessment of clinical studies included in the evidence review</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng196er7tab3"><a href="/books/NBK571346/table/niceng196er7.tab3/?report=objectonly" target="object" title="Table 3" class="img_link icnblk_img figpopup" rid-figpopup="figniceng196er7tab3" rid-ob="figobniceng196er7tab3"><img class="small-thumb" src="/books/NBK571346/table/niceng196er7.tab3/?report=thumb" src-large="/books/NBK571346/table/niceng196er7.tab3/?report=previmg" alt="Table 3. Clinical evidence summary: Discontinuation versus continuation of oral anticoagulants in people with AF resolved by ablation." /></a><div class="icnblk_cntnt"><h4 id="niceng196er7.tab3"><a href="/books/NBK571346/table/niceng196er7.tab3/?report=objectonly" target="object" rid-ob="figobniceng196er7tab3">Table 3</a></h4><p class="float-caption no_bottom_margin">Clinical evidence summary: Discontinuation versus continuation of oral anticoagulants in people with AF resolved by ablation. </p></div></div><p>See <a href="#niceng196er7.appf">appendix F</a> for full GRADE tables.</p></div></div><div id="niceng196er7.s1.6"><h3>1.6. Economic evidence</h3><div id="niceng196er7.s1.6.1"><h4>1.6.1. Included studies</h4><p>No relevant health economic studies were identified.</p></div><div id="niceng196er7.s1.6.2"><h4>1.6.2. Excluded studies</h4><p>No health economic studies that were relevant to this question were excluded due to assessment of limited applicability or methodological limitations.</p><p>See also the health economic study selection flow chart in <a href="#niceng196er7.appg">appendix G</a>.</p></div><div id="niceng196er7.s1.6.3"><h4>1.6.3. Unit costs</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng196er7tab4"><a href="/books/NBK571346/table/niceng196er7.tab4/?report=objectonly" target="object" title="Table 4" class="img_link icnblk_img figpopup" rid-figpopup="figniceng196er7tab4" rid-ob="figobniceng196er7tab4"><img class="small-thumb" src="/books/NBK571346/table/niceng196er7.tab4/?report=thumb" src-large="/books/NBK571346/table/niceng196er7.tab4/?report=previmg" alt="Table 4. UK costs of anticoagulants." /></a><div class="icnblk_cntnt"><h4 id="niceng196er7.tab4"><a href="/books/NBK571346/table/niceng196er7.tab4/?report=objectonly" target="object" rid-ob="figobniceng196er7tab4">Table 4</a></h4><p class="float-caption no_bottom_margin">UK costs of anticoagulants. </p></div></div><p>For warfarin there is also the cost of monitoring. In the previous update of the guideline (CG180), the annual cost of warfarin monitoring (anticoagulation clinic) was reported in the costing template and inflated to 2017/2018 costs (using OECD Purchasing Power Parities):<a class="bibr" href="#niceng196er7.ref47" rid="niceng196er7.ref47"><sup>47</sup></a>£251a year.<a class="bibr" href="#niceng196er7.ref41" rid="niceng196er7.ref41"><sup>41</sup></a></p></div></div><div id="niceng196er7.s1.7"><h3>1.7. The committee’s discussion of the evidence</h3><div id="niceng196er7.s1.7.1"><h4>1.7.1. Interpreting the evidence</h4><div id="niceng196er7.s1.7.1.1"><h5>1.7.1.1. The outcomes that matter most</h5><p>All outcomes listed in the protocol for this review, which comprised health-related quality of life, mortality, stroke or thromboembolic complications, major bleeding, recurrent atrial fibrillation and exacerbation of heart failure, were considered by the committee to be critical for decision-making. No additional important outcomes were specified in the protocol.</p><p>In this review, no clinical evidence was identified for the following critical outcomes: health-related quality of life, mortality and exacerbation of heart failure.</p></div><div id="niceng196er7.s1.7.1.2"><h5>1.7.1.2. The quality of the evidence</h5><p>The quality of the evidence for all outcomes included in this review was of very low quality according to GRADE analysis. One of the main reasons for this was the fact that all evidence was obtained from only one study that was observational in design as it was a retrospective cohort study. These study designs have inherent issues with selection bias as assignment to different intervention groups has not been performed randomly and is likely to be based on one or more patient characteristics, meaning the participants within each group are more likely to differ in terms of their characteristics and prognosis. These differences between the groups may contribute to any differences observed in the effectiveness of the different treatments and lead to inappropriate conclusions being made. The committee considered the risk of bleeding and risk of stroke to be important confounders for this review, and for this reason only observational studies that had adjusted for or were similar at baseline for these two factors were included in this review.</p><p>Issues with blinding, incomplete outcome data and outcome reporting bias, which are components of the risk of bias assessment alongside selection bias, were also present for some of the outcomes in this review.</p><p>In addition to risk of bias, the presence of imprecision in all of the outcomes included in this review also contributed to the very low quality rating that was obtained.</p></div><div id="niceng196er7.s1.7.1.3"><h5>1.7.1.3. Benefits and harms</h5><p>The evidence included in this review was obtained from a single retrospective cohort study. There was some evidence based on point estimates for two outcomes (transient ischaemic attack and recurrence of atrial fibrillation) of a clinical benefit of discontinuing warfarin (switching to aspirin) compared to continuing warfarin; however, uncertainty surrounding the point estimates made it difficult to determine a clear benefit of either one of the interventions. The point estimates for the stroke and major bleeding outcomes suggested a slight clinical benefit of continuation of warfarin compared to discontinuation (switching to aspirin), though the absolute values suggested that only 1 more per 1000 would experience each of these events in the discontinuation group compared with the continuation group, which may represent no clinically important difference between the two groups. Substantial uncertainty around the point estimate was also observed for the stroke and major bleeding outcomes, which meant the committee could not be sure of the true effect.</p><p>Overall, the committee agreed that the uncertainty in the evidence for all outcomes was too high to come to any firm conclusions based on the evidence presented. The committee agreed that further research is required into the use of anticoagulation following successful resolution of AF following ablation or cardiac surgery, and made research recommendations in this area.</p><p>In addition, the committee noted that a paper was identified during the scoping phase which reported on a cohort of patients who were recorded as ‘resolved atrial fibrillation’ on GP registers. These patients had not undergone either ablation or cardiac surgery. The committee noted that paroxysmal atrial fibrillation could easily be missed, and it did not consider that any patient who had not undergone either ablation or cardiac surgery should be considered to have resolved atrial fibrillation. It was noted that the paper actually reported a much higher incidence of stroke or transient ischaemic attack in the resolved atrial fibrillation group compared with the controls without atrial fibrillation. This strongly suggests that atrial fibrillation is continuing in many of those classified as having resolved atrial fibrillation in the study. Based on this, the committee made a consensus-based recommendation that anticoagulation should only be stopped in people with a diagnosis of atrial fibrillation based on a risk assessment that includes the person’s CHA2DS2-VASc and ORBIT scores, even if they now appear to be in sinus rhythm and atrial fibrillation is not detected. This recommendation would also include people where an attempt to resolve their atrial fibrillation has been made, for example by ablation or cardioversion, as there was insufficient evidence available to inform different recommendations.</p></div></div><div id="niceng196er7.s1.7.2"><h4>1.7.2. Cost effectiveness and resource use</h4><p>No relevant health economic analyses were identified for this review; therefore unit costs were presented to aid committee consideration of cost effectiveness. The unit costs of anticoagulants were presented alongside the cost of monitoring for warfarin. There was insufficient clinical evidence and no health economic evidence to support a recommendation concerning the discontinuation of anticoagulation following successful resolution of atrial fibrillation. The committee were concerned about the potential harms of discontinuing anticoagulants based solely on the absence of AF. As a result they agreed to make a consensus recommendation not to discontinue anticoagulants unless based on a risk assessment that includes the person’s CHA2DS2-VASc and ORBIT scores, whether or not their atrial fibrillation is still detectable, as well as consideration of patient preferences. This is considered current practice and so it is anticipated that there will be no impact on NHS resources.</p></div></div></div><div id="niceng196er7.rl.r1"><h2 id="_niceng196er7_rl_r1_">References</h2><dl class="temp-labeled-list"><dl class="bkr_refwrap"><dt>1.</dt><dd><div class="bk_ref" id="niceng196er7.ref1">Adderley
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et al. Thromboembolic events and need for anticoagulation therapy following left atrial appendage occlusion in patients with electrical isolation of the appendage. Journal of Cardiovascular Electrophysiology. 2019; 30(4):511–516 [<a href="https://pubmed.ncbi.nlm.nih.gov/30623500" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30623500</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>19.</dt><dd><div class="bk_ref" id="niceng196er7.ref19">Gallo
|
|
C, Battaglia
|
|
A, Anselmino
|
|
M, Bianchi
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F, Grossi
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S, Nangeroni
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G
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et al. Long-term events following atrial fibrillation rate control or transcatheter ablation: a multicenter observational study. Journal of Cardiovascular Medicine. 2016; 17(3):187–193 [<a href="https://pubmed.ncbi.nlm.nih.gov/26237425" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26237425</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>20.</dt><dd><div class="bk_ref" id="niceng196er7.ref20">Garcia-Fernandez
|
|
A, Marin
|
|
F, Roldan
|
|
V, Galcera-Jornet
|
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E, Martinez-Martinez
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JG, Valdes
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M
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et al. The HAS-BLED score predicts long-term major bleeding and death in anticoagulated non-valvular atrial fibrillation patients undergoing electrical cardioversion. International Journal of Cardiology. 2016; 217:42–48 [<a href="https://pubmed.ncbi.nlm.nih.gov/27179207" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27179207</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>21.</dt><dd><div class="bk_ref" id="niceng196er7.ref21">Garcia-Fernandez
|
|
A, Marin
|
|
F, Roldan
|
|
V, Gomez-Sansano
|
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JM, Hernandez-Romero
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D, Valdes
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M
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et al. Long-term predictors of thromboembolic events in nonvalvular atrial fibrillation patients undergoing electrical cardioversion. Circulation Journal. 2016; 80(3):605–612 [<a href="https://pubmed.ncbi.nlm.nih.gov/26763488" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26763488</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>22.</dt><dd><div class="bk_ref" id="niceng196er7.ref22">Geis
|
|
N, Raake
|
|
P, Kiriakou
|
|
C, Mereles
|
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D, Frankenstein
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L, Abu-Sharar
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H
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et al. Temporary oral anticoagulation after MitraClip-a strategy to lower the incidence of post-procedural stroke?
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RM, Nagendran
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M, Maruthappu
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M. Is it safe to stop anticoagulants after successful surgery for atrial fibrillation?
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|
|
DR, Reddy
|
|
VY, Turi
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ZG, Doshi
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SK, Sievert
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H, Buchbinder
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M
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|
|
AA, Saliba
|
|
WI, Martin
|
|
DO, Bhargava
|
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M, Sherman
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M, Magnelli-Reyes
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C
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et al. Natural history and long-term outcomes of ablated atrial fibrillation. Circulation: Arrhythmia and Electrophysiology. 2011; 4(3):271–278 [<a href="https://pubmed.ncbi.nlm.nih.gov/21493959" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21493959</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>26.</dt><dd><div class="bk_ref" id="niceng196er7.ref26">Jacobs
|
|
V, May
|
|
HT, Bair
|
|
TL, Crandall
|
|
BG, Cutler
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DM, Day
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JD
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|
|
DO, Melduni
|
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RM, Lahr
|
|
B, Yao
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X, Greason
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KL, Noseworthy
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PA. Evaluation of anticoagulation use and subsequent stroke in patients with atrial fibrillation after empiric surgical left atrial appendage closure: A retrospective case-control study. Clinical Cardiology. 2018; 41(12):1578–1582 [<a href="/pmc/articles/PMC6351070/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6351070</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30144129" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30144129</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>28.</dt><dd><div class="bk_ref" id="niceng196er7.ref28">Kim
|
|
DH, Lee
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DI, Ahn
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J, Lee
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KN, Roh
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SY, Shim
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J
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VHR, Schuster
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P. Adherence to oral anticoagulant treatment and risk factor assessment six months after DC-conversion of atrial fibrillation. Scandinavian Cardiovascular Journal. 2020; 54(3):179–185 [<a href="https://pubmed.ncbi.nlm.nih.gov/31913722" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31913722</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>30.</dt><dd><div class="bk_ref" id="niceng196er7.ref30">Kochhauser
|
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S, Alipour
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P, Haig-Carter
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T, Trought
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K, Hache
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P, Khaykin
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|
|
U, Tondo
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C, Camm
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J, Diener
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HC, Paul
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V, Schmidt
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et al. Left atrial appendage occlusion with the AMPLATZER amulet device: one-year follow-up from the prospective global Amulet observational registry. EuroIntervention. 2018; 14(5):e590–e597 [<a href="https://pubmed.ncbi.nlm.nih.gov/29806820" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29806820</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>32.</dt><dd><div class="bk_ref" id="niceng196er7.ref32">Lauritzen
|
|
DJ, Vodstrup
|
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HJ, Christensen
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TD, Hald
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MO, Christensen
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R, Heiberg
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J. Discontinuation of anticoagulants after successful surgical ablation of atrial fibrillation. Journal of Cardiac Surgery. 2020; 35(9):2216–2223 [<a href="https://pubmed.ncbi.nlm.nih.gov/32720353" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32720353</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>33.</dt><dd><div class="bk_ref" id="niceng196er7.ref33">Li
|
|
Y, Liu
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W, Liu
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X, Shen
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H, Hou
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F, Jin
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|
|
JJ, Elafros
|
|
MA, Mullen
|
|
MT, Muser
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D, Hayashi
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T, Enriquez
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A
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N, Crusius
|
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L, Haussig
|
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S, Woitek
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FJ, Kiefer
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P, Stachel
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|
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DT, Bersohn
|
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MM, Waldo
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AL, Wathen
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MS, Choucair
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WK, Lip
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GY
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|
|
J, Gualis
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J, Marcos-Vidal
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JM, Buber
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J, Martin
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CE, Gomez-Plana
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J
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et al. Efficacy of oral anticoagulation in stroke prevention among sinus-rhythm patients who lack left atrial mechanical contraction after cryoablation. Texas Heart Institute Journal. 2015; 42(5):430–437 [<a href="/pmc/articles/PMC4591881/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4591881</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/26504435" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26504435</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>38.</dt><dd><div class="bk_ref" id="niceng196er7.ref38">Murashita
|
|
T, Rankin
|
|
JS, Wei
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|
LM, Roberts
|
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HG, Alkhouli
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MA, Badhwar
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V. Oral anticoagulation may not be necessary for patients discharged in sinus rhythm after the Cox Maze IV procedure. The Journal of thoracic and cardiovascular surgery. 2018; 155(3):997–1006 [<a href="https://pubmed.ncbi.nlm.nih.gov/29274913" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29274913</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>39.</dt><dd><div class="bk_ref" id="niceng196er7.ref39">Nademanee
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|
K, Amnueypol
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M, Lee
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F, Drew
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CM, Suwannasri
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W, Schwab
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MC
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K, Naito
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S, Sasaki
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T, Take
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Y, Minami
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K, Kitagawa
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JM, Kuck
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KH, Andresen
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|
D, Steven
|
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D, Spitzer
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SG, Hoffmann
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K, Aonuma
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K, Kumagai
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K, Hirao
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K, Inoue
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K, Kimura
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|
|
Y, Nagashima
|
|
K, Arai
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M, Watanabe
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R, Yokoyama
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K, Matsumoto
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H, Chugh
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A, Ozaydin
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M, Good
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AF, Choi
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AS, Le
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QT, Ko
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DT, Han
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JK, Park
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M, Franca
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LR, Teutsch
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C, Diener
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HC, Lu
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S, Dubner
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SJ
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MR, Hellkamp
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AS, Lokhnygina
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Y, Piccini
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JP, Zhang
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|
|
S, Cote
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R, White-Guay
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B, Dorais
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M, Oussaid
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E, Schnitzer
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M, Robertson
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JO, Bailey
|
|
M, Guthrie
|
|
TJ, Moon
|
|
MR, Lawton
|
|
JS
|
|
et al. The impact of CHADS2 score on late stroke after the Cox maze procedure. The Journal of thoracic and cardiovascular surgery. 2013; 146(1):85–89 [<a href="/pmc/articles/PMC4369384/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4369384</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/22818126" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22818126</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>53.</dt><dd><div class="bk_ref" id="niceng196er7.ref53">Potpara
|
|
TS, Larsen
|
|
TB, Deharo
|
|
JC, Rossvoll
|
|
O, Dagres
|
|
N, Todd
|
|
D
|
|
et al. Oral anticoagulant therapy for stroke prevention in patients with atrial fibrillation undergoing ablation: results from the First European Snapshot Survey on Procedural Routines for Atrial Fibrillation Ablation (ESS-PRAFA). Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology. 2015; 17(6):986–993 [<a href="https://pubmed.ncbi.nlm.nih.gov/26023177" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26023177</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>54.</dt><dd><div class="bk_ref" id="niceng196er7.ref54">Reddy
|
|
VY, Doshi
|
|
SK, Sievert
|
|
H, Buchbinder
|
|
M, Neuzil
|
|
P, Huber
|
|
K
|
|
et al. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-year follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) trial. Circulation. 2013; 127(6):720–729 [<a href="https://pubmed.ncbi.nlm.nih.gov/23325525" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23325525</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>55.</dt><dd><div class="bk_ref" id="niceng196er7.ref55">Reynolds
|
|
MR, Allison
|
|
JS, Natale
|
|
A, Weisberg
|
|
IL, Ellenbogen
|
|
KA, Richards
|
|
M
|
|
et al. A prospective randomized trial of apixaban dosing during atrial fibrillation ablation: the AEIOU Trial. JACC: Clinical Electrophysiology. 2018; 4(5):580–588 [<a href="https://pubmed.ncbi.nlm.nih.gov/29798783" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29798783</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>56.</dt><dd><div class="bk_ref" id="niceng196er7.ref56">Riley
|
|
MP, Zado
|
|
E, Hutchinson
|
|
MD, Lin
|
|
D, Bala
|
|
R, Garcia
|
|
FC
|
|
et al. Risk of stroke or transient ischemic attack after atrial fibrillation ablation with oral anticoagulant use guided by ECG monitoring and pulse assessment. Journal of Cardiovascular Electrophysiology. 2014; 25(6):591–596 [<a href="https://pubmed.ncbi.nlm.nih.gov/24533561" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24533561</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>57.</dt><dd><div class="bk_ref" id="niceng196er7.ref57">Romero
|
|
J, Avendano
|
|
R, Diaz
|
|
JC, Taveras
|
|
J, Lupercio
|
|
F, Di Biase
|
|
L. Is it safe to stop oral anticoagulation after catheter ablation for atrial fibrillation?
|
|
Expert Review of Cardiovascular Therapy. 2019; 17(1):31–41 [<a href="https://pubmed.ncbi.nlm.nih.gov/30460874" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30460874</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>58.</dt><dd><div class="bk_ref" id="niceng196er7.ref58">Saad
|
|
EB, d’Avila
|
|
A, Costa
|
|
IP, Aryana
|
|
A, Slater
|
|
C, Costa
|
|
RE
|
|
et al. Very low risk of thromboembolic events in patients undergoing successful catheter ablation of atrial fibrillation with a CHADS2 score ≤3: a long-term outcome study. Circulation: Arrhythmia and Electrophysiology. 2011; 4(5):615–621 [<a href="https://pubmed.ncbi.nlm.nih.gov/21841192" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21841192</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>59.</dt><dd><div class="bk_ref" id="niceng196er7.ref59">Saglietto
|
|
A, De Ferrari
|
|
GM, Gaita
|
|
F, Anselmino
|
|
M. Short-term anticoagulation after acute cardioversion of early-onset atrial fibrillation. European Journal of Clinical Investigation. 2020; 50:e13316 [<a href="https://pubmed.ncbi.nlm.nih.gov/32535904" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32535904</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>60.</dt><dd><div class="bk_ref" id="niceng196er7.ref60">Sakamoto
|
|
Y, Okubo
|
|
S, Nito
|
|
C, Nishiyama
|
|
Y, Suda
|
|
S, Matsumoto
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|
N
|
|
et al. Ischemic stroke during anticoagulant interruption by healthcare professionals in stroke patients with atrial fibrillation. Journal of the Neurological Sciences. 2019; 400:113–118 [<a href="https://pubmed.ncbi.nlm.nih.gov/30925358" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30925358</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>61.</dt><dd><div class="bk_ref" id="niceng196er7.ref61">Sambola
|
|
A, Bueno
|
|
H, Miranda
|
|
B, Hernandez
|
|
AV, Limeres
|
|
J, del Blanco
|
|
BG
|
|
et al. Safe and efficacious use of 1-month triple therapy in patients with atrial fibrillation and high bleeding risk undergoing PCI. Cardiovascular Drugs and Therapy. 2019; 33(4):425–433 [<a href="https://pubmed.ncbi.nlm.nih.gov/31332653" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31332653</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>62.</dt><dd><div class="bk_ref" id="niceng196er7.ref62">Schlingloff
|
|
F, Oberhoffer
|
|
M, Quasdorff
|
|
I, Wohlmuth
|
|
P, Schmoeckel
|
|
M, Geidel
|
|
S. Oral anticoagulation after successful atrial fibrillation ablation operations: is it necessary?
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|
Annals of Thoracic Surgery. 2016; 101(4):1471–1476 [<a href="https://pubmed.ncbi.nlm.nih.gov/26627178" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26627178</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>63.</dt><dd><div class="bk_ref" id="niceng196er7.ref63">Shah
|
|
AN, Mittal
|
|
S, Sichrovsky
|
|
TC, Cotiga
|
|
D, Arshad
|
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A, Maleki
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K
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et al. Long-term outcome following successful pulmonary vein isolation: pattern and prediction of very late recurrence. Journal of Cardiovascular Electrophysiology. 2008; 19(7):661–667 [<a href="https://pubmed.ncbi.nlm.nih.gov/18284502" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18284502</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>64.</dt><dd><div class="bk_ref" id="niceng196er7.ref64">Shah
|
|
RR, Pillai
|
|
A, Schafer
|
|
P, Meggo
|
|
D, McElderry
|
|
T, Plumb
|
|
V
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|
et al. Safety and efficacy of uninterrupted apixaban therapy versus warfarin during atrial fibrillation ablation. American Journal of Cardiology. 2017; 120(3):404–407 [<a href="https://pubmed.ncbi.nlm.nih.gov/28595862" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28595862</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>65.</dt><dd><div class="bk_ref" id="niceng196er7.ref65">Sjalander
|
|
S, Holmqvist
|
|
F, Smith
|
|
JG, Platonov
|
|
PG, Kesek
|
|
M, Svensson
|
|
PJ
|
|
et al. Assessment of use vs discontinuation of oral anticoagulation after pulmonary vein isolation in patients with atrial fibrillation. JAMA Cardiology. 2017; 2(2):146–152 [<a href="https://pubmed.ncbi.nlm.nih.gov/27893055" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27893055</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>66.</dt><dd><div class="bk_ref" id="niceng196er7.ref66">Solla-Ruiz
|
|
I, Villanueva-Benito
|
|
I, Paredes-Galan
|
|
E, Salterain-Gonzalez
|
|
N, Oria-Gonzalez
|
|
G, De La Cuesta-Arzamendi
|
|
F
|
|
et al. Differences between patient-driven adherence to vitamin K antagonists and direct oral anticoagulants. Do few missed doses matter? ACO-MEMS Study. Thrombosis Research. 2019; 179:20–27 [<a href="https://pubmed.ncbi.nlm.nih.gov/31075697" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31075697</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>67.</dt><dd><div class="bk_ref" id="niceng196er7.ref67">Sondergaard
|
|
L, Wong
|
|
YH, Reddy
|
|
VY, Boersma
|
|
LVA, Bergmann
|
|
MW, Doshi
|
|
S
|
|
et al. Propensity-matched comparison of oral anticoagulation versus antiplatelet therapy after left atrial appendage closure with WATCHMAN. JACC: Cardiovascular Interventions. 2019; 12(11):1055–1063 [<a href="https://pubmed.ncbi.nlm.nih.gov/31171282" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31171282</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>68.</dt><dd><div class="bk_ref" id="niceng196er7.ref68">Tao
|
|
H, Ma
|
|
C, Dong
|
|
J, Liu
|
|
X, Long
|
|
D, Yu
|
|
R. Late thromboembolic events after circumferential pulmonary vein ablation of atrial fibrillation. Journal of Interventional Cardiac Electrophysiology. 2010; 27(1):33–39 [<a href="https://pubmed.ncbi.nlm.nih.gov/19937096" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19937096</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>69.</dt><dd><div class="bk_ref" id="niceng196er7.ref69">Tao
|
|
S, Otomo
|
|
K, Ono
|
|
Y, Osaka
|
|
Y, Hirao
|
|
T, Koura
|
|
K
|
|
et al. Efficacy and safety of uninterrupted rivaroxaban taken preoperatively for radiofrequency catheter ablation of atrial fibrillation compared to uninterrupted warfarin. Journal of Interventional Cardiac Electrophysiology. 2017; 48(2):167–175 [<a href="https://pubmed.ncbi.nlm.nih.gov/27943112" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27943112</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>70.</dt><dd><div class="bk_ref" id="niceng196er7.ref70">Themistoclakis
|
|
S, Corrado
|
|
A, Marchlinski
|
|
FE, Jais
|
|
P, Zado
|
|
E, Rossillo
|
|
A
|
|
et al. The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation. Journal of the American College of Cardiology. 2010; 55(8):735–743 [<a href="https://pubmed.ncbi.nlm.nih.gov/20170810" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20170810</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>71.</dt><dd><div class="bk_ref" id="niceng196er7.ref71">Tingting
|
|
C, Yuzhu
|
|
W, Lin
|
|
Z, Ran
|
|
L, Jing
|
|
L, Yi
|
|
W
|
|
et al. Utilization of anticoagulants in nonvalvular atrial fibrillation before and after catheter ablation at Shanghai, China. Clinical and Applied Thrombosis/Hemostasis. 2019; doi: 10.1177/1076029619826260 [<a href="/pmc/articles/PMC6714957/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6714957</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30754983" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30754983</span></a>] [<a href="http://dx.crossref.org/10.1177/1076029619826260" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">CrossRef</a>]</div></dd></dl><dl class="bkr_refwrap"><dt>72.</dt><dd><div class="bk_ref" id="niceng196er7.ref72">Tran
|
|
VN, Tessitore
|
|
E, Gentil-Baron
|
|
P, Jannot
|
|
AS, Sunthorn
|
|
H, Burri
|
|
H
|
|
et al. Thromboembolic events 7-11 years after catheter ablation of atrial fibrillation. Pacing and Clinical Electrophysiology. 2015; 38(4):499–506 [<a href="https://pubmed.ncbi.nlm.nih.gov/25626468" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25626468</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>73.</dt><dd><div class="bk_ref" id="niceng196er7.ref73">Tse
|
|
HF, Lau
|
|
CP. Bleeding and thromboembolic risks of internal cardioversion for persistent atrial fibrillation. Pacing and Clinical Electrophysiology. 2002; 25(12):1752–1755 [<a href="https://pubmed.ncbi.nlm.nih.gov/12520677" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12520677</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>74.</dt><dd><div class="bk_ref" id="niceng196er7.ref74">Uhm
|
|
JS, Won
|
|
H, Joung
|
|
B, Nam
|
|
GB, Choi
|
|
KJ, Lee
|
|
MH
|
|
et al. Safety and efficacy of switching anticoagulation to aspirin three months after successful radiofrequency catheter ablation of atrial fibrillation. Yonsei Medical Journal. 2014; 55(5):1238–1245 [<a href="/pmc/articles/PMC4108807/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4108807</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25048480" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25048480</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>75.</dt><dd><div class="bk_ref" id="niceng196er7.ref75">Weimar
|
|
T, Schena
|
|
S, Bailey
|
|
MS, Maniar
|
|
HS, Schuessler
|
|
RB, Cox
|
|
JL
|
|
et al. The cox-maze procedure for lone atrial fibrillation: a single-center experience over 2 decades. Circulation: Arrhythmia and Electrophysiology. 2012; 5(1):8–14 [<a href="/pmc/articles/PMC3288520/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3288520</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/22095640" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22095640</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>76.</dt><dd><div class="bk_ref" id="niceng196er7.ref76">Winkle
|
|
RA, Mead
|
|
RH, Engel
|
|
G, Kong
|
|
MH, Patrawala
|
|
RA. Discontinuing anticoagulation following successful atrial fibrillation ablation in patients with prior strokes. Journal of Interventional Cardiac Electrophysiology. 2013; 38(3):147–153 [<a href="/pmc/articles/PMC3825152/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3825152</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24101149" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24101149</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>77.</dt><dd><div class="bk_ref" id="niceng196er7.ref77">Yagishita
|
|
A, Takahashi
|
|
Y, Takahashi
|
|
A, Fujii
|
|
A, Kusa
|
|
S, Fujino
|
|
T
|
|
et al. Incidence of late thromboembolic events after catheter ablation of atrial fibrillation. Circulation Journal. 2011; 75(10):2343–2349 [<a href="https://pubmed.ncbi.nlm.nih.gov/21778595" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21778595</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>78.</dt><dd><div class="bk_ref" id="niceng196er7.ref78">Yang
|
|
WY, Du
|
|
X, Jiang
|
|
C, He
|
|
L, Fawzy
|
|
AM, Wang
|
|
L
|
|
et al. The safety of discontinuation of oral anticoagulation therapy after apparently successful atrial fibrillation ablation: a report from the Chinese Atrial Fibrillation Registry study. Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology. 2020; 22(1):90–99 [<a href="https://pubmed.ncbi.nlm.nih.gov/31909431" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31909431</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>79.</dt><dd><div class="bk_ref" id="niceng196er7.ref79">Zado
|
|
ES, Pammer
|
|
M, Parham
|
|
T, Lin
|
|
D, Frankel
|
|
DS, Dixit
|
|
S
|
|
et al. “As Needed” nonvitamin K antagonist oral anticoagulants for infrequent atrial fibrillation episodes following atrial fibrillation ablation guided by diligent pulse monitoring: a feasibility study. Journal of Cardiovascular Electrophysiology. 2019; 30(5):631–638 [<a href="https://pubmed.ncbi.nlm.nih.gov/30706975" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30706975</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>80.</dt><dd><div class="bk_ref" id="niceng196er7.ref80">Zhang
|
|
L, Jiang
|
|
S, Ren
|
|
C, Gao
|
|
C. Is long-term warfarin therapy necessary in Chinese patients with atrial fibrillation after bioprosthetic mitral valve replacement and left atrial appendage obliteration?
|
|
Heart Surgery Forum. 2015; 18(1):E11–16 [<a href="https://pubmed.ncbi.nlm.nih.gov/25881216" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25881216</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>81.</dt><dd><div class="bk_ref" id="niceng196er7.ref81">Zhao
|
|
Y, Lu
|
|
Y, Qin
|
|
Y. A meta-analysis of randomized controlled trials of uninterrupted periprocedural anticoagulation strategy in patients undergoing atrial fibrillation catheter ablation. International Journal of Cardiology. 2018; 270:167–171 [<a href="https://pubmed.ncbi.nlm.nih.gov/29903520" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29903520</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>82.</dt><dd><div class="bk_ref" id="niceng196er7.ref82">Zhou
|
|
Z, Yu
|
|
J, Carcel
|
|
C, Delcourt
|
|
C, Shan
|
|
J, Lindley
|
|
RI
|
|
et al. Resuming anticoagulants after anticoagulation-associated intracranial haemorrhage: systematic review and meta-analysis. BMJ Open. 2018; 8(5):e019672 [<a href="/pmc/articles/PMC5961574/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5961574</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/29764874" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29764874</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>83.</dt><dd><div class="bk_ref" id="niceng196er7.ref83">Zink
|
|
MD, Chua
|
|
W, Zeemering
|
|
S, di Biase
|
|
L, Antoni
|
|
BL, David
|
|
C
|
|
et al. Predictors of recurrence of atrial fibrillation within the first 3 months after ablation. Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology. 2020; 22(9):1337–1344 [<a href="/pmc/articles/PMC7478316/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7478316</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32725107" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32725107</span></a>]</div></dd></dl></dl></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng196er7.appa"><h3>Appendix A. Review protocols</h3><p id="niceng196er7.appa.et1"><a href="/books/NBK571346/bin/niceng196er7-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Table 5. Review protocol: Discontinuation of anticoagulants following resolution of AF</a><span class="small"> (PDF, 167K)</span></p><p id="niceng196er7.appa.et2"><a href="/books/NBK571346/bin/niceng196er7-appa-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Table 6. Health economic review protocol</a><span class="small"> (PDF, 133K)</span></p></div><div id="niceng196er7.appb"><h3>Appendix B. Literature search strategies</h3><p><i>The search strategy will be added here after rerun searches have been conducted.</i></p><p>This literature search strategy was used for the following reviews:
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<ul><li class="half_rhythm"><div><b>What is the clinical and cost effectiveness of discontinuing anticoagulation in people whose atrial fibrillation has resolved?</b></div></li></ul></p><p>The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.<a class="bibr" href="#niceng196er7.ref42" rid="niceng196er7.ref42"><sup>42</sup></a></p><p>For more information, please see the <a href="/books/NBK571346/bin/niceng196er7_bm1.pdf">Methods</a> Report published as part of the accompanying documents for this guideline.</p><p id="niceng196er7.appb.et1"><a href="/books/NBK571346/bin/niceng196er7-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">B.1. Clinical search literature search strategy</a><span class="small"> (PDF, 312K)</span></p><p id="niceng196er7.appb.et2"><a href="/books/NBK571346/bin/niceng196er7-appb-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">B.2. Health Economics literature search strategy</a><span class="small"> (PDF, 212K)</span></p></div><div id="niceng196er7.appc"><h3>Appendix C. Clinical evidence selection</h3><p id="niceng196er7.appc.et1"><a href="/books/NBK571346/bin/niceng196er7-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Figure 1. Flow chart of clinical study selection for the review of discontinuation of anticoagulants following resolution of AF</a><span class="small"> (PDF, 41K)</span></p></div><div id="niceng196er7.appd"><h3>Appendix D. Clinical evidence tables</h3><p id="niceng196er7.appd.et1"><a href="/books/NBK571346/bin/niceng196er7-appd-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (147K)</span></p></div><div id="niceng196er7.appe"><h3>Appendix E. Forest plots</h3><p id="niceng196er7.appe.et1"><a href="/books/NBK571346/bin/niceng196er7-appe-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">E.1. Resolution after ablation stratum</a><span class="small"> (PDF, 28K)</span></p></div><div id="niceng196er7.appf"><h3>Appendix F. GRADE tables</h3><p id="niceng196er7.appf.et1"><a href="/books/NBK571346/bin/niceng196er7-appf-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Table 9. Clinical evidence profile: Discontinuation versus continuation of oral anticoagulants in people with AF resolved by ablation</a><span class="small"> (PDF, 65K)</span></p></div><div id="niceng196er7.appg"><h3>Appendix G. Health economic evidence selection</h3><p id="niceng196er7.appg.et1"><a href="/books/NBK571346/bin/niceng196er7-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Figure 6. Flow chart of health economic study selection for the guideline</a><span class="small"> (PDF, 165K)</span></p></div><div id="niceng196er7.apph"><h3>Appendix H. Health economic evidence tables</h3><p>None.</p></div><div id="niceng196er7.appi"><h3>Appendix I. Excluded studies</h3><div id="niceng196er7.appi.s1"><h4>I.1. Excluded clinical studies</h4><p id="niceng196er7.appi.et1"><a href="/books/NBK571346/bin/niceng196er7-appi-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (69K)</span></p></div><div id="niceng196er7.appi.s2"><h4>I.2. Excluded health economic studies</h4><p>None.</p></div></div><div id="niceng196er7.appj"><h3>Appendix J. Research recommendations</h3><p id="niceng196er7.appj.et1"><a href="/books/NBK571346/bin/niceng196er7-appj-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">J.1. Discontinuing anticoagulation following resolution of post-cardiac surgery AF</a><span class="small"> (PDF, 95K)</span></p><p id="niceng196er7.appj.et2"><a href="/books/NBK571346/bin/niceng196er7-appj-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">J.2. Discontinuing anticoagulation following ablation</a><span class="small"> (PDF, 95K)</span></p></div></div></div><div class="fm-sec"><div><p>Final</p></div><div><p>Intervention evidence review</p><p>Developed by the National Guideline Centre, Royal College of Physicians</p></div><div><p><b>Disclaimer</b>: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.</p><p>Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="http://wales.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2021.</div><div class="small"><span class="label">Bookshelf ID: NBK571346</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/34165936" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">34165936</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng196er7tab1"><div id="niceng196er7.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">PICO characteristics of review question</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK571346/table/niceng196er7.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng196er7.tab1_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng196er7.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng196er7.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People aged over 18, with all of the following:
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<ul><li class="half_rhythm"><div>a previous diagnosis of AF</div></li><li class="half_rhythm"><div>using OACs, at least until study inception</div></li><li class="half_rhythm"><div>experiencing current ‘resolution’ of AF</div></li></ul>
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‘Resolution’ is that defined by the clinician.</td></tr><tr><th id="hd_b_niceng196er7.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><td headers="hd_b_niceng196er7.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Discontinuation of anticoagulants</td></tr><tr><th id="hd_b_niceng196er7.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><td headers="hd_b_niceng196er7.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Continuation of anticoagulants at previous dose</td></tr><tr><th id="hd_b_niceng196er7.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><td headers="hd_b_niceng196er7.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>Critical</u>
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<ul><li class="half_rhythm"><div>health-related quality of life</div></li><li class="half_rhythm"><div>mortality</div></li><li class="half_rhythm"><div>stroke or thromboembolic complications</div></li><li class="half_rhythm"><div>major bleeding</div></li><li class="half_rhythm"><div>recurrent atrial fibrillation</div></li><li class="half_rhythm"><div>Exacerbation of heart failure.</div></li></ul></td></tr><tr><th id="hd_b_niceng196er7.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design</th><td headers="hd_b_niceng196er7.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Randomised controlled trials, SRs of RCTs, and prospective/retrospective cohort studies (with adjustment for stroke risk and risk of bleeding).</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng196er7tab2"><div id="niceng196er7.tab2" class="table"><h3><span class="label">Table 2</span><span class="title">Summary of studies included in the evidence review</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK571346/table/niceng196er7.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng196er7.tab2_lrgtbl__"><table><thead><tr><th id="hd_h_niceng196er7.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng196er7.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention and comparison</th><th id="hd_h_niceng196er7.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><th id="hd_h_niceng196er7.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><th id="hd_h_niceng196er7.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comments</th></tr></thead><tbody><tr><td headers="hd_h_niceng196er7.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Uhm 2014<a class="bibr" href="#niceng196er7.ref74" rid="niceng196er7.ref74"><sup>74</sup></a></p><p>Retrospective cohort</p><p>N=608</p></td><td headers="hd_h_niceng196er7.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Discontinuation of anticoagulants: switching warfarin to aspirin(n=296).</p><p>At 3 months post-successful ablation, switched from warfarin to 100 mg aspirin.</p><p>If a recurrence occurred following initiation of this intervention, warfarin was restarted.</p><p>Continuation of anticoagulants: continuation of warfarin anticoagulation(n=312).</p><p>At 3 months post-successful ablation, warfarin anticoagulation continued.</p></td><td headers="hd_h_niceng196er7.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>People aged 18 years and over with AF resolved by catheter ablation, using warfarin prior to ablation.</p><p>Does not explicitly state non-valvular AF but no mention of any concomitant valve disease.</p><p>Predominantly (>75% in each group) paroxysmal AF.</p><p>AF resolution: If no recurrence of AF at 3 months following ablation, determined by Holter monitoring, ablation successful and included in the study.</p></td><td headers="hd_h_niceng196er7.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Stroke or thromboembolic complications (stroke and transient ischaemic attack)</p><p>Major bleeding</p><p>Recurrent atrial fibrillation</p><p>Mean follow-up duration of 18±12.2 months</p></td><td headers="hd_h_niceng196er7.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Does not specify the dose of warfarin prior to successful resolution by ablation (does not state that it was changed/altered, so have not rated down for indirectness).</p><p>Mean CHADSVASc score: 1.45±1.34 (discontinuation) and 1.55±1.36 (continuation)</p><p>Mean HAS-BLED score: 1.37±0.83 (discontinuation) and 1.45±1.02 (continuation)</p><p>Although mean CHADVASc scores similar between groups, lower proportion in discontinuation group with previous stroke/TIA compared with continuation group (7.1% vs. 14.5%).</p><p>Time in therapeutic range of INR was 44.2% across the follow-up – low and could contribute to the lack of differences observed between the two groups for outcomes?</p></td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng196er7tab3"><div id="niceng196er7.tab3" class="table"><h3><span class="label">Table 3</span><span class="title">Clinical evidence summary: Discontinuation versus continuation of oral anticoagulants in people with AF resolved by ablation</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK571346/table/niceng196er7.tab3/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng196er7.tab3_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng196er7.tab3_1_1_1_1" rowspan="2" colspan="1" headers="hd_h_niceng196er7.tab3_1_1_1_1" style="text-align:left;vertical-align:bottom;">Outcomes</th><th id="hd_h_niceng196er7.tab3_1_1_1_2" rowspan="2" colspan="1" headers="hd_h_niceng196er7.tab3_1_1_1_2" style="text-align:left;vertical-align:bottom;"><p>No of Participants (studies)</p><p>Follow up</p></th><th id="hd_h_niceng196er7.tab3_1_1_1_3" rowspan="2" colspan="1" headers="hd_h_niceng196er7.tab3_1_1_1_3" style="text-align:left;vertical-align:bottom;">Quality of the evidence (GRADE)</th><th id="hd_h_niceng196er7.tab3_1_1_1_4" rowspan="2" colspan="1" headers="hd_h_niceng196er7.tab3_1_1_1_4" style="text-align:left;vertical-align:bottom;">Relative effect (95% CI)</th><th id="hd_h_niceng196er7.tab3_1_1_1_5" colspan="2" rowspan="1" style="text-align:left;vertical-align:bottom;">Anticipated absolute effects</th></tr><tr><th headers="hd_h_niceng196er7.tab3_1_1_1_5" id="hd_h_niceng196er7.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Risk with continuation of anticoagulants (at previous dose)</th><th headers="hd_h_niceng196er7.tab3_1_1_1_5" id="hd_h_niceng196er7.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Risk difference with Discontinuation of anticoagulants (95% CI)</th></tr></thead><tbody><tr><td headers="hd_h_niceng196er7.tab3_1_1_1_1" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;">Stroke</td><td headers="hd_h_niceng196er7.tab3_1_1_1_2" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;"><p>578</p><p>(1 study)</p><p>18±12.2 months</p></td><td headers="hd_h_niceng196er7.tab3_1_1_1_3" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;"><p>⊕⊝⊝⊝</p><p>VERY LOW<sup>a</sup><sup>,</sup><sup>b</sup></p><p>due to risk of bias, imprecision</p></td><td headers="hd_h_niceng196er7.tab3_1_1_1_4" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;">Peto OR 1.17 (0.07 to 18.98)</td><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_1 hd_h_niceng196er7.tab3_1_1_2_2" colspan="2" rowspan="1" style="text-align:left;vertical-align:top;">Moderate</td></tr><tr><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">3 per 1000</td><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>1 more per 1000</p><p>(from 3 fewer to 51 more)</p></td></tr><tr><td headers="hd_h_niceng196er7.tab3_1_1_1_1" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;">Transient ischaemic attack</td><td headers="hd_h_niceng196er7.tab3_1_1_1_2" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;"><p>578</p><p>(1 study)</p><p>18±12.2 months</p></td><td headers="hd_h_niceng196er7.tab3_1_1_1_3" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;"><p>⊕⊝⊝⊝</p><p>VERY LOW<sup>a</sup><sup>,</sup><sup>b</sup></p><p>due to risk of bias, imprecision</p></td><td headers="hd_h_niceng196er7.tab3_1_1_1_4" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;">Peto OR 0.16 (0.01 to 2.53)</td><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_1 hd_h_niceng196er7.tab3_1_1_2_2" colspan="2" rowspan="1" style="text-align:left;vertical-align:top;">Moderate</td></tr><tr><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">6 per 1000</td><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>10 fewer per 1000</p><p>(from 20 fewer to 0 more)<sup>c</sup></p></td></tr><tr><td headers="hd_h_niceng196er7.tab3_1_1_1_1" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;">Major bleeding</td><td headers="hd_h_niceng196er7.tab3_1_1_1_2" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;"><p>578</p><p>(1 study)</p><p>18±12.2 months</p></td><td headers="hd_h_niceng196er7.tab3_1_1_1_3" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;"><p>⊕⊝⊝⊝</p><p>VERY LOW<sup>a</sup><sup>,</sup><sup>b</sup></p><p>due to risk of bias, imprecision</p></td><td headers="hd_h_niceng196er7.tab3_1_1_1_4" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;">Peto OR 1.17 (0.16 to 8.43)</td><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_1 hd_h_niceng196er7.tab3_1_1_2_2" colspan="2" rowspan="1" style="text-align:left;vertical-align:top;">Moderate</td></tr><tr><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">6 per 1000</td><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>1 more per 1000</p><p>(from 5 fewer to 42 more)</p></td></tr><tr><td headers="hd_h_niceng196er7.tab3_1_1_1_1" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;">Recurrence of atrial fibrillation</td><td headers="hd_h_niceng196er7.tab3_1_1_1_2" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;"><p>608</p><p>(1 study)</p><p>18±12.2 months</p></td><td headers="hd_h_niceng196er7.tab3_1_1_1_3" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;"><p>⊕⊝⊝⊝</p><p>VERY LOW<sup>a</sup><sup>,</sup><sup>b</sup></p><p>due to risk of bias, imprecision</p></td><td headers="hd_h_niceng196er7.tab3_1_1_1_4" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;">RR 0.85 (0.54 to 1.35)</td><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_1 hd_h_niceng196er7.tab3_1_1_2_2" colspan="2" rowspan="1" style="text-align:left;vertical-align:top;">Moderate</td></tr><tr><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">119 per 1000</td><td headers="hd_h_niceng196er7.tab3_1_1_1_5 hd_h_niceng196er7.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>18 fewer per 1000</p><p>(from 55 fewer to 42 more)</p></td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>a</dt><dd><div id="niceng196er7.tab3_1"><p class="no_margin">Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias</p></div></dd></dl><dl class="bkr_refwrap"><dt>b</dt><dd><div id="niceng196er7.tab3_2"><p class="no_margin">Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs</p></div></dd></dl><dl class="bkr_refwrap"><dt>c</dt><dd><div id="niceng196er7.tab3_3"><p class="no_margin">Zero events in one arm (intervention group) so absolute value calculated manually from risk difference</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng196er7tab4"><div id="niceng196er7.tab4" class="table"><h3><span class="label">Table 4</span><span class="title">UK costs of anticoagulants</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK571346/table/niceng196er7.tab4/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng196er7.tab4_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng196er7.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Drug</th><th id="hd_h_niceng196er7.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Daily dose</th><th id="hd_h_niceng196er7.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost – per day</th><th id="hd_h_niceng196er7.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost – per year</th></tr></thead><tbody><tr><td headers="hd_h_niceng196er7.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Apixaban tablet</td><td headers="hd_h_niceng196er7.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">2.5-5mg twice daily</td><td headers="hd_h_niceng196er7.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£1.90</td><td headers="hd_h_niceng196er7.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£693.50</td></tr><tr><td headers="hd_h_niceng196er7.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Dabigatran capsule</td><td headers="hd_h_niceng196er7.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">110-150mg twice daily</td><td headers="hd_h_niceng196er7.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£1.70</td><td headers="hd_h_niceng196er7.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£620.50</td></tr><tr><td headers="hd_h_niceng196er7.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Edoxaban tablet</td><td headers="hd_h_niceng196er7.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">60mg once daily</td><td headers="hd_h_niceng196er7.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£1.75</td><td headers="hd_h_niceng196er7.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£638.75</td></tr><tr><td headers="hd_h_niceng196er7.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Rivaroxaban tablet</td><td headers="hd_h_niceng196er7.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">20mg once daily</td><td headers="hd_h_niceng196er7.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£1.80</td><td headers="hd_h_niceng196er7.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£657.00</td></tr><tr><td headers="hd_h_niceng196er7.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Warfarin tablet</td><td headers="hd_h_niceng196er7.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">5mg daily<sup>(a)</sup></td><td headers="hd_h_niceng196er7.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.02</td><td headers="hd_h_niceng196er7.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£5.74</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">Sources: Dosing and unit costs from BNFonline<a class="bibr" href="#niceng196er7.ref9" rid="niceng196er7.ref9"><sup>9</sup></a>, accessed January 2020, with exception of unit cost for warfarin: eMIT<a class="bibr" href="#niceng196er7.ref12" rid="niceng196er7.ref12"><sup>12</sup></a>, accessed January 2020.</p></div></dd></dl><dl class="bkr_refwrap"><dt>(a)</dt><dd><div id="niceng196er7.tab4_1"><p class="no_margin">Assumed here to be an average daily dose of 5mg. Initially 5–10 mg, to be taken on day 1; subsequent doses dependent on the prothrombin time, reported as INR (international normalised ratio), a lower induction dose can be given over 3–4 weeks in patients who do not require rapid anticoagulation, elderly patients to be given a lower induction dose; maintenance 3–9 mg daily, to be taken at the same time each day.</p></div></dd></dl></dl></div></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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