Chapter 10 168 Discussion In part I we evaluated the periprocedural use of DOAC on thromboembolism and bleeding events, and if undiagnosed SDB had an impact on AF recurrence after catheter ablation. The management of AF has evolved significantly over the past decade, in which special attention has been paid to the treatment of modifiable risk factors (e.g., hypertension, obesity, smoking, alcohol, lack of exercise) and the value of having a multidisciplinary team. We also observed a change from a rate control strategy to a rhythm control strategy for symptomatic patients with AF. This is primarily attributed to improved efficacy and safety of AF ablation procedures rather than the development of new antiarrhythmic drugs. As mentioned earlier, another important development was the introduction of DOAC in 2016 in the Netherlands, including the factor IIa inhibitors (dabigatran) and Xa inhibitors (rivaroxaban, apixaban, edoxaban). Large RCT’s have clearly demonstrated a reduction in bleeding events with a similar preventive effect on thromboembolic events in patients with non-valvular AF (6). The safety profile of DOACs have resulted in their widespread acceptance, which has, in turn, led to them largely supplanting VKAs in the treatment of the majority of patients with atrial fibrillation. Notable exceptions are patients with mechanical valves, end-stage renal disease and frail elderly (FRAIL-AF) (14). The increased use of DOAC also had a major impact on the management of patients with AF who presented in hospitals for an electrical cardioversion or AF ablation. After the introduction of DOAC, the lack of an antidote caused hesitation among operators to conduct an invasive AF procedure while the patient was using DOAC. We evaluated a minimally interrupted DOAC strategy (discontinuation 24 hour before procedure) in patients undergoing AF ablation and this was associated with a similar safety profile as uninterrupted VKA. Furthermore, several randomized trials have demonstrated the safety of uninterrupted DOAC, and this is now the standard approach in most EP hospitals, including ours. Novel oral anticoagulants are being developed, like the factor XIa inhibitors (e.g., asundexian, milvexian), with a presumed better safety profile (less bleeding) than the current DOACs. Unfortunately, clinical trials (e.g., OCEANIC-AF) have shown a
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