Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

Are there data supporting the discontinuance of warfarin after catheter ablation for atrial fibrillation? What is the prevalence of symptomatic and asymptomatic atrial fibrillation after catheter ablation?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Immediate discontinuation of warfarin following catheter ablation versus early discontinuation versus tailored discontinuation using arrhythmia monitoring (e.g. Holter monitor)

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Patients with atrial fibrillation who have undergone catheter ablation

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Subgroups stratified by CHADS2 score (i.e. comorbidities – Congestive heart failure, Hypertension, Age > 75 years, Diabetes mellitus, Stroke – that may add to a patient’s thromboembolic risk)

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

All patient-related benefits, including but not limited to: reduction in significant bleeding, mortality, and/or strokes/transient ischemic attacks

Describe any health-related risks, side effects, or harms that you are concerned about.

All patient-related harms, including but not limited to: significant bleeding, mortality, strokes/transient ischemic attacks

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cardiovascular disease, including stroke and hypertension

AHRQ Priority Populations

• Minority groups
• Women
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

Compared with pharmacologic therapy, catheter ablation of atrial fibrillation may be an attractive treatment option for patients seeking to avoid long-term anticoagulation with warfarin. One study demonstrated that discontinuation of warfarin therapy after catheter ablation may be safe, but sufficient evidence from a randomized trial is lacking (Circulation, 114 (2006), pp. 759–765) Furthermore, atrial fibrillation can recur after catheter ablation (J Cardiovasc Electrophysiol, 17 (2006), pp. 1080–1085; J Cardiovasc Electrophysiol, 17 (2006), pp. 231–235; J Am Coll Cardiol, 44 (2004), pp. 869–877; J Cardiovasc Electrophysiol, 17 (2006), pp. 134–139).

With a lack of randomized data, the 2007 HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation recommends that discontinuation of warfarin therapy post ablation is generally not recommended in patients with additional risk factors (congestive heart failure, history of high blood pressure, age (75 years) diabetes, prior stroke or transient ischemic attack (CHADS2) score ?2 (Heart Rhythm. 2007 Jun;4(6):816-61). Evidence synthesis is needed to support the efficacy of catheter ablation in preventing recurrent atrial fibrillation and whether warfarin can be discontinued.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

This topic was ranked as a priority by a panel of stakeholders convened through the Duke EPC’s Cardiovascular Topic Identification project to recommend a research agenda for future systematic reviews within the EHC cardiovascular domain.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Stakeholders considered uncertainty for clinicians and/or policy-makers as part of the ranking process, and with that criterion considered, this topic received a priority designation.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

This topic was identified by a group of stakeholders in cardiovascular disease as an area in which significant morbidity, mortality, and/or variation in resource utilization persists, and future systematic review development should be prioritized. Answers to this question are expected to inform practice and guideline development, and ultimately improve the quality of care by reducing morbidity, mortality, and costs.

Describe the timeframe in which an answer to your question is needed.

Though no specific timeframe is applicable, this topic was identified by the stakeholder group as immediately relevant.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Stakeholders considered variation in clinical practice and inequities in care as part of the ranking process, and with that criterion considered, this topic received a priority designation.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

This topic was identified by a group of stakeholders in cardiovascular disease as an area in which significant morbidity, mortality, and/or variation in resource utilization persists, and future systematic review development should be prioritized. Answers to this question are expected to inform practice and guideline development, and ultimately improve the quality of care by reducing morbidity, mortality, and costs.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

Involvement in the Evidence-based Practice Center Program