Are Three Weeks of Oral Anticoagulation Sufficient for Safe Cardioversion in Atrial Fibrillation?

Abstract

Background and Objectives: Patients with atrial fibrillation (AF), lasting >48 h, considered for cardioversion, are recommended ≥3 weeks of oral anticoagulation before sinus rhythm restoration because of high risk of development of left atrial thrombosis (LAT) and stroke. However, the optimal duration of anticoagulation in the presence of overt LAT is unknown. Materials and Methods: An open-label study aimed to investigate the prevalence of spontaneous echo contrast (SEC) and LAT before and after 3 weeks of direct oral anticoagulant (DOAC) treatment. We included 51 consecutive patients (50.9% males), mean age 69.3 ± 7.4 years with paroxysmal/unknown duration of AF, considered for cardioversion, who agreed to have transesophageal echocardiography at enrollment and 3 weeks later. Results: At baseline SEC was present in 26 (50.9%) and LAT in 10 (19.6%) of 51 patients. After 3 weeks on DOAC, SEC persisted in 12 (25.0%) and LAT in 7 (14.5%) of 48 patients, p < 0.05 vs. baseline. Factors, associated most strongly with persistence of SEC/LAT, were left atrial appendage (LAA) emptying velocity <20 cm/s (OR = 2.82), LAA lobes >2 (OR = 1.84), and indexed left atrial volume ≥34 mL/m2 (OR = 1.37). Conclusions: In our study the incidence of SEC/LAT, particularly in AF with unknown duration, was not as low as we expected. The prevalence of SEC/LAT seemed to be dependent on factors not routinely evaluated in AF patients planned for cardioversion (indexed LA volume, LAA morphology and number of lobules, LAA emptying velocity, etc.). Our data suggested an individualized approach for DOAC duration in AF patients before an attempt for restoration of sinus rhythm is made, taking into consideration the LAA morphology and function.

Emergency department management of atrial fibrillation: 2023 consensus from the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of Cardiology (SEC), and the Spanish Society of Thrombosis and Hemostasis (SETH)

“…Se debe anticoagular previamente al paciente durante un mínimo de 3 semanas y continuar con la anticoagulación durante un mínimo de 4 semanas después de la misma. La duración exacta de la anticoagulación antes y después de la cardioversión no se ha analizado en ensayos clínicos aleatorizados 77 , e incluso algunos estudios demuestran la persistencia de trombos o "efecto humo" en la orejuela a pesar del tratamiento anticoagulante 77,78 . El periodo de 3 semanas se ha establecido de forma arbitraria y se basa en el tiempo presumiblemente necesario para la endotelización o resolución de trombos preexistentes.…”

Asymptomatic Stroke in the Setting of Percutaneous Non-Coronary Intervention Procedures

“…Amongst patients with an identified left atrial thrombus/spontaneous echo contrast, some predictors of thrombosis nonresolution after 3 weeks of anticoagulation have been identified: LAA emptying velocities < 20 cm/s at transesophageal echocardiography, an indexed left atrial volume > 40 mL/m 2 and a multilobular LAA. [80] Anticoagulation with Vitamin K Antagonists (VKAs) or Direct Oral Anticoagulants (DOACs), following annual stroke-risk evaluation with the CHA 2 DS 2 -VASc score, represents the standard care in patients with AF, in order to prevent stroke and peripheral embolization [75,81]. Although these drugs are widely used, and DOACs have shown non-inferiority-and sometimes even superiority-for stroke prevention while having significantly fewer bleeding complications compared to Warfarin [82][83][84][85], some issues still remain a matter of debate, including contraindications, side effects and adherence.…”

Application of Dense Neural Networks for Detection of Atrial Fibrillation and Ranking of Augmented ECG Feature Set

“…This rhythm disorder is associated with substantial morbidity and mortality, mostly due to ischemic strokes: ~20% of the non-anticoagulated AF patients will develop a stroke, and one of three to five strokes is due to AF. The significant burden to patients and healthcare systems globally, related to AF complications, necessitates the early diagnosing of this arrhythmia [ 1 , 2 , 3 , 4 ].…”

“…However, in the real clinical practice, many patients with recurrent episodes of paroxysmal AF are often in normal sinus rhythm at the time of clinical visits [ 1 , 6 ]. On the other hand, short and asymptomatic AF episodes possess similar stoke potential as the longer ones, and it is not uncommon AF patients to present first with an ischemic stroke [ 1 , 2 , 3 ]. Since standard 12-lead ECG strips during clinical visits are unreliable to confirm or reject recurrent episodes of AF, clinicians count a lot on ECG monitoring techniques like 24–72 h Holter-ECG monitors and loop recorders, tracing patient’s rhythm for days to several weeks [ 1 , 6 , 7 ].…”