Duration of warfarin sodium therapy prior to electrical cardioversion of atrial fibrillation

Abstract

Objectives. To evaluate the duration of anticoagulation treatment with warfarin sodium before elective DC-cardioversion and to identify clinical variables predicting short-term versus long-term waiting times. Design. Retrospective. Subjects. Patients with a known start date for warfarin sodium, a known duration of atrial fibrillation (AF) and who underwent DC-cardioversion were included. Main outcome measures. Duration of treatment with warfarin sodium prior to DC-cardioversion. Methods. The hospital records of 288 consecutive patients with AF scheduled for elective cardioversion at two hospitals in Stockholm were reviewed. Only patients with a known start date for warfarin sodium and known duration of AF were included in the study.Results. The median age was 70 (26-85) years and the duration of AF at time of cardioversion were 18 weeks (5-273) weeks. The median treatment duration prior to cardioversion with warfarin sodium was 12 weeks. Sinus rhythm was established in 224 (78%) patients of which 90 (40%) remained in sinus rhythm 1 month after cardioversion. In multivariate analysis, the only independent predictor of short waiting times for cardioversion (8 vs. 15 weeks) was if a cardiologist instituted the treatment with warfarin sodium (P < 0.001, 95% CI 5.0-9.0). Conclusion. The average waiting time from start of warfarin sodium treatment to elective cardioversion exceeds by far the recommended 3-4 weeks on therapeutic international normalized ratio (INR). In order to minimize the time period until cardioversion significant changes in the out-of-hospital care logistics has to be undertaken.

Findings of transoesophageal echocardiogram in appropriately anticoagulated patients with persistent atrial fibrillation prior to planned cardioversion

“…In order to assure appropriate use of the drug, more strict control is required. This is why additional TEE is being performed, even in patients properly prepared with OACs for planned SR restoration [ 1 , 6 , 9 ]. We did not find any relationship between the decision to perform TEE and the estimated CHA2DS2-VASc score.…”

“…Therefore, the duration of preparation for scheduled cardioversion lasts from two to three months [ 8 , 9 ]. The action of NOACs is stable, dosage is simple, preparation for scheduled SR restoration is shorter.…”

Anticoagulation in the cardiac patient: A concise review

“…44 Transesophageal echocardiography may be used to guide cardioversion in patients with atrial fibrillation who desire early cardioversion. 45 While warfarin has been used for decades to anticoagulate patients undergoing cardioversion, 46 DOACs have recently been evaluated as an alternative method of anticoagulation in this setting. The ENSURE-AF trial compared edoxaban to warfarin for stroke prevention in 2199 patients undergoing electrical cardioversion.…”

Real‐life experience with non‐vitamin K antagonist oral anticoagulants versus warfarin in patients undergoing elective cardioversion of atrial fibrillation

“…Due to their rapid onset of action, their predictable pharmacokinetics and pharmacodynamics and their ability to be used at fixed doses without routine laboratory monitoring, NOACs offer potential advantages over VKAs and may shorten the waiting times for elective cardioversions (Cappato et al., 2014; Ezekowitz et al., 2018; Goette et al., 2016). At the beginning of warfarin therapy, a labile international normalized ratio (INR) is common, which may prolong the time until ECV can be performed (Ryman, Frick, Frykman, & Rosenqvist, 2003). As an alternative to preprocedural anticoagulation, transesophageal echocardiography (TOE) is useful to exclude cardiac thrombus to facilitate early cardioversion (Kirchhof et al., 2016).…”