The optimal range of international normalized ratio for radiofrequency catheter ablation of atrial fibrillation during therapeutic anticoagulation with warfarin

Jin-Seok Kim, Krit Jongnarangsin, Rakesh Latchamsetty, Aman Chugh, Hamid Ghanbari, Thomas Crawford, Miki Yokokawa, Eric Good, Frank Bogun, Frank Pelosi, Fred Morady, Hakan Oral

Research output: Contribution to journalArticle

30 Citations (Scopus)

Abstract

Background-Uninterrupted anticoagulation with warfarin during radiofrequency catheter ablation (RFA) of atrial fibrillation is associated with a lower risk of periprocedural complications than when warfarin is temporarily discontinued. However, the optimal international normalized ratio (INR) levels during RFA have not been defined. Methods and Results-In this retrospective analysis, RFA was performed in 1133 consecutive patients (mean age, 61±10 years) with paroxysmal (550) or persistent atrial fibrillation (583). Patients were grouped based on the INR on the day of RFA. There was a quadratic relationship between the INR and bleeding and vascular complications (P<0.001). Complications were less prevalent when INR was ≥2.0 and ≤3.0 (5% [31/572]) than when INR was <2.0 (10% [49/485]; P=0.004) and >3.0 (12% [9/76]; P=0.03). The prevalence of pericardial tamponade (1%) was similar at all INRs. From the quadratic model, the optimal range of INR was calculated as 2.1 to 2.5. INRs<2.0 and >3.0 were associated with a >2-fold increase in complications, with a further steep rise beyond an INR>3.5. Concomitant clopidogrel use was associated with a significant increase in complications at all INRs (odds ratio=3.1; ±95% confidence interval, 1.4-7.4). Unfractionated heparin requirements to maintain a therapeutic activated clotting time during RFA was reduced by 50% in patients with an INR>2.0. Conclusions-The optimal INR range during uninterrupted periprocedural anticoagulation using warfarin is narrow. Therefore, INR levels should be carefully monitored in preparation for RFA of atrial fibrillation.

Original languageEnglish
Pages (from-to)302-309
Number of pages8
JournalCirculation: Arrhythmia and Electrophysiology
Volume6
Issue number2
DOIs
Publication statusPublished - 2013 Apr 1
Externally publishedYes

Fingerprint

International Normalized Ratio
Catheter Ablation
Warfarin
Atrial Fibrillation
Therapeutics
clopidogrel
Cardiac Tamponade
Blood Vessels
Heparin
Odds Ratio
Confidence Intervals
Hemorrhage

Keywords

  • Ablation
  • Atrial fibrillation
  • Bleeding
  • Complication
  • Warfarin

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

The optimal range of international normalized ratio for radiofrequency catheter ablation of atrial fibrillation during therapeutic anticoagulation with warfarin. / Kim, Jin-Seok; Jongnarangsin, Krit; Latchamsetty, Rakesh; Chugh, Aman; Ghanbari, Hamid; Crawford, Thomas; Yokokawa, Miki; Good, Eric; Bogun, Frank; Pelosi, Frank; Morady, Fred; Oral, Hakan.

In: Circulation: Arrhythmia and Electrophysiology, Vol. 6, No. 2, 01.04.2013, p. 302-309.

Research output: Contribution to journalArticle

Kim, J-S, Jongnarangsin, K, Latchamsetty, R, Chugh, A, Ghanbari, H, Crawford, T, Yokokawa, M, Good, E, Bogun, F, Pelosi, F, Morady, F & Oral, H 2013, 'The optimal range of international normalized ratio for radiofrequency catheter ablation of atrial fibrillation during therapeutic anticoagulation with warfarin', Circulation: Arrhythmia and Electrophysiology, vol. 6, no. 2, pp. 302-309. https://doi.org/10.1161/CIRCEP.112.000143
Kim, Jin-Seok ; Jongnarangsin, Krit ; Latchamsetty, Rakesh ; Chugh, Aman ; Ghanbari, Hamid ; Crawford, Thomas ; Yokokawa, Miki ; Good, Eric ; Bogun, Frank ; Pelosi, Frank ; Morady, Fred ; Oral, Hakan. / The optimal range of international normalized ratio for radiofrequency catheter ablation of atrial fibrillation during therapeutic anticoagulation with warfarin. In: Circulation: Arrhythmia and Electrophysiology. 2013 ; Vol. 6, No. 2. pp. 302-309.
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abstract = "Background-Uninterrupted anticoagulation with warfarin during radiofrequency catheter ablation (RFA) of atrial fibrillation is associated with a lower risk of periprocedural complications than when warfarin is temporarily discontinued. However, the optimal international normalized ratio (INR) levels during RFA have not been defined. Methods and Results-In this retrospective analysis, RFA was performed in 1133 consecutive patients (mean age, 61±10 years) with paroxysmal (550) or persistent atrial fibrillation (583). Patients were grouped based on the INR on the day of RFA. There was a quadratic relationship between the INR and bleeding and vascular complications (P<0.001). Complications were less prevalent when INR was ≥2.0 and ≤3.0 (5{\%} [31/572]) than when INR was <2.0 (10{\%} [49/485]; P=0.004) and >3.0 (12{\%} [9/76]; P=0.03). The prevalence of pericardial tamponade (1{\%}) was similar at all INRs. From the quadratic model, the optimal range of INR was calculated as 2.1 to 2.5. INRs<2.0 and >3.0 were associated with a >2-fold increase in complications, with a further steep rise beyond an INR>3.5. Concomitant clopidogrel use was associated with a significant increase in complications at all INRs (odds ratio=3.1; ±95{\%} confidence interval, 1.4-7.4). Unfractionated heparin requirements to maintain a therapeutic activated clotting time during RFA was reduced by 50{\%} in patients with an INR>2.0. Conclusions-The optimal INR range during uninterrupted periprocedural anticoagulation using warfarin is narrow. Therefore, INR levels should be carefully monitored in preparation for RFA of atrial fibrillation.",
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AU - Jongnarangsin, Krit

AU - Latchamsetty, Rakesh

AU - Chugh, Aman

AU - Ghanbari, Hamid

AU - Crawford, Thomas

AU - Yokokawa, Miki

AU - Good, Eric

AU - Bogun, Frank

AU - Pelosi, Frank

AU - Morady, Fred

AU - Oral, Hakan

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N2 - Background-Uninterrupted anticoagulation with warfarin during radiofrequency catheter ablation (RFA) of atrial fibrillation is associated with a lower risk of periprocedural complications than when warfarin is temporarily discontinued. However, the optimal international normalized ratio (INR) levels during RFA have not been defined. Methods and Results-In this retrospective analysis, RFA was performed in 1133 consecutive patients (mean age, 61±10 years) with paroxysmal (550) or persistent atrial fibrillation (583). Patients were grouped based on the INR on the day of RFA. There was a quadratic relationship between the INR and bleeding and vascular complications (P<0.001). Complications were less prevalent when INR was ≥2.0 and ≤3.0 (5% [31/572]) than when INR was <2.0 (10% [49/485]; P=0.004) and >3.0 (12% [9/76]; P=0.03). The prevalence of pericardial tamponade (1%) was similar at all INRs. From the quadratic model, the optimal range of INR was calculated as 2.1 to 2.5. INRs<2.0 and >3.0 were associated with a >2-fold increase in complications, with a further steep rise beyond an INR>3.5. Concomitant clopidogrel use was associated with a significant increase in complications at all INRs (odds ratio=3.1; ±95% confidence interval, 1.4-7.4). Unfractionated heparin requirements to maintain a therapeutic activated clotting time during RFA was reduced by 50% in patients with an INR>2.0. Conclusions-The optimal INR range during uninterrupted periprocedural anticoagulation using warfarin is narrow. Therefore, INR levels should be carefully monitored in preparation for RFA of atrial fibrillation.

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