STROKE-VT: DOACs superior to aspirin at stroke prevention after LV arrhythmia ablation
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Among patients who underwent left ventricular arrhythmia ablation with a radiofrequency catheter, direct oral anticoagulants were superior to aspirin in preventing cerebrovascular events, according to the results of the STROKE-VT trial.
For the trial, presented at Heart Rhythm 2021 and simultaneously published in JACC: Clinical Electrophysiology, Dhanunjaya R. Lakkireddy, MD, FHRS, medical director of the Kansas City Heart Rhythm Institute at HCA Midwest Health in Overland, Kansas, and colleagues randomly assigned 246 patients who underwent LV arrhythmia ablation — for ventricular tachycardia or premature ventricular contraction — with a radiofrequency catheter to receive a direct oral anticoagulant (DOAC) or aspirin 3 hours after achieving hemostasis following the procedure.
The primary endpoint was stroke, transient ischemic attack or MRI-detected asymptomatic cerebrovascular event at 24 hours and 30 days.
According to the researchers, post-procedure stroke was lower in the DOAC group than in the aspirin group (0% vs. 6.5%; P < .001), as was post-procedure TIA (4.9% vs. 18%; P < .001).
The rate of MRI-detected asymptomatic cerebrovascular events was lower in the DOAC group at 24 hours (12% vs. 23%; P = .03) and at 30 days (6.5% vs. 18%; P = .006), the researchers found.
There were no differences between the groups in acute procedure-related complications (DOAC, 12%; aspirin, 16%; P = .7) and in in-hospital mortality (DOAC, 3.7%; aspirin, 2.7%; P = .73), according to the researchers.
“An interesting thing we found is that a large portion of patients had a retrograde aortic approach, and when they had [that], or they had prolonged procedural times or ablation times, or when their left ventricular ejection fraction was significantly lower, the risk of thromboembolic events dramatically increases,” Lakkireddy said during a press conference.
The mean age of the cohort was 60 years, and 83% were men. Among the cohort, 74.8% had the procedure for ventricular tachycardia and the rest had it for premature ventricular contraction.
“The take-home message from this particular study is that when we do left ventricular ablations, it is important to anticoagulate these people with a direct oral anticoagulant or an equivalent in order to mitigate the risk of systemic thromboembolic events, and whenever there is an opportunity, we should avoid a retrograde transaortic approach,” Lakkireddy said during the press conference.
In a related editorial published in JACC: Clinical Electrophysiology, Jeffrey R. Winterfield, MD, Hank and Laurel Greer Endowed Chair in Cardiac Electrophysiology at the Medical University of South Carolina, and Usha Tedrow, MD, MSc, director of the clinical cardiac electrophysiology program and the cardiac arrhythmia service at Brigham and Women’s Hospital and associate professor of medicine at Harvard Medical School, wrote that the study “represents a first-ever prospective analysis of strategies to reduce thromboembolic complications following catheter ablation for ventricular arrhythmias. The authors should be congratulated for this important work, which will have important ramifications for future clinical practice and guidelines. With this new trial, the ventricular arrhythmia field has now emulated its northerly neighbor, the atrium, with the demonstration that DOAC use in a randomized trial can reduce thromboembolic complications following catheter ablation of ventricular arrhythmias.”
References:
- Lakkireddy DR, et al. JACC Clin Electrophysiol. 2021;doi:10.1016/j.jacep.2021.07.010.
- Winterfield JR, et al. JACC Clin Electrophysiol. 2021;doi:10.1016/j.jacep.2021.07.011.
Perspective
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We have learned that after VT ablation, patients should receive DOACs as opposed to aspirin. This can significantly reduce the risk for TIAs and strokes postprocedurally in these patients.
The study has elegantly shown that DOACs should become standard practice. Many centers such as ours at Massachusetts General Hospital have been doing this already, but it was nice to see this tested prospectively in a randomized way. It will certainly solidify this end of the practice.
The big question is, how long do you continue the DOAC? Is the duration of therapy dependent on the extent of ablation, the amount of scar and the LVEF? I am not sure we have a consensus on this.
It remains disconcerting that the incidence of TIAs and asymptomatic cerebral events in DOAC arm, albeit reduced compared with aspirin, are still fairly high. There is still much work to do on this front to make LV endocardial ablations safer.
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Lakkireddy DR, et al. LBCT-01-01. Presented at: Heart Rhythm 2021; July 28-31, 2021 (hybrid meeting).
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