Page 81 - ADD-ON ABLATION SURGERY IN PATIENTS WITH ATRIAL FIBRILLATION

months) whereas there was a propensity to under-treat high-risk patients (31% at inclusion 40% at 12 months).
These results are in agreement with previous findings regarding over- and under- treatment of OAC in AF patients55, 56. Similarly, Dagres et al.57 demonstrated that OAC after catheter ablation was not guided by the patient’s individual stroke risk with resulting over-treatment of low-risk patients and under-treatment of high-risk patients. These authors found that the most important factor influencing the use of OAC was the detection of AF recurrences during follow- up. However, to the best of our knowledge, our study is the first to explore OAC appropriateness following surgical ablation and our findings may have important clinical consequences since the guideline-deviant management has been shown to be associated with a worse outcome in daily practice58.
One major reason for the inappropriate antithrombotic therapy is possibly due to lack of education, but also insufficient communication between cardiac surgeons and general practitioners/referring cardiologists. Indeed, it should be emphasised that in the patients of this study, the final decision on anticoagulation treatment was made by the general practitioner or by the referring cardiologist in consultation with the patient, and not by the tertiary centre that gave only a recommendation.
In addition, appropriate treatment is further hampered by the introduction of
different stroke risk stratification models in clinical practice which, although widely
applied, have shown a suboptimal predictive value leading to misclassification of
the individual patient risk, as shown recently for the CHADS2 scheme59, 60.This has
undoubtedly contributed to making some physicians reluctant to prescribe OAC
only on the basis of these risk-score schemes. Moreover, there are conflicting
data regarding the risk conferred by certain factors that are included in some
of the risk models but not in others61. Finally, the lack of large randomised
trials regarding the necessity and efficacy of anticoagulation after a presumably
successful surgical procedure might also be responsible for poor guideline-
adherence of antithrombotic treatment following ablation surgery. 9 As a result, the choice of appropriate antithrombotic therapy for the individual
AF patient is still debated62, 63 and it is not clear whether the standard scheme of OAC therapy is optimal for all patients after surgical ablation or if this scheme should be modified according to other factors rather than CHADS2 score.This is confirmed, in our study by multivariate analysis, which showed that the effect of the CHADS2 score on anticoagulation at admission was not significant. In
General discussion
199