2 pilot studies have been published looking at the following question: can patients take anticoagulation only when they are in AFIB and not during other times?
What makes this feasible is the availability of the DOACs (direct anticoagulants) which start acting in 2 hours unlike the older drug warfarin that would take 3-5 days to achieve therapeutic levels.
What argues against this approach is that it does not take into account that AFIB may be a marker for a systemic process that increases the risk of stroke and that the individual episode of AFIB may have to do nothing with the overall risk of stroke. See AFIB and inflammation.
TACTIC-AF pilot study
TACTIC -AF pilot study was published in Heart Rhythm journal in 2018.
This study aims to answer the question – is on-again, off-again anti-coagulation with DOAC (direct anticoagulants like Pradaxa, Eliquis and Xarelto) safe and feasible?
All patients in this pilot study had implantable loop recorders (SJM/Abbott CONFIRM). TACTIC-AF pilot study used the following protocol.
TACTIC-AF remote monitoring and anticoagulation protocol. Patients would stop anticoagulation if they were free of an episode of AT/AF lasting >6 minutes and a total daily AT/AF burden >6 hours for 30 consecutive days. Once off anticoagulation, patients would resume anticoagulation for an episode of AT/AF lasting >6 minutes or a total daily AT/AF burden >6 hours
Tailored anticoagulation resulted in a 75% reduction in time on anticoagulation compared to standard of care with continuous anticoagulation regardless of AF burden.
REACT.COM pilot study
REACT.COM (not a website) pilot study was published in JACC in 2015.
This study used Medtronic REVEAL ILR to assess AF burden in patients with a CHADS2 score of 1–2 and infrequent AF episodes. The study protocol was slightly different (patients would stop DOAC if they remained free of continuous episodes of AT/AF lasting >1 hour for 30 continuous days, resuming DOAC if they experienced a continuous AT/AF episode lasting >1 hour). This study demonstrated a 94% reduction in time on anticoagulation.