Risk for Clinical Thromboembolism Associated with Conversion to Sinus Rhythm in Patients with Atrial Fibrillation Lasting Less Than 48 Hours

Weigner, Marilyn J.; Caulfield, Todd A.; Danias, Peter G.; Silverman, David I.; Manning, Warren J.

doi:10.7326/0003-4819-126-8-199704150-00005

Cited by 213 publications

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“…The only predictor of increased probability of spontaneous cardioversion was atrial fibrillation duration of <24 hours; 21 similar results were reported by Tejan-Sie and colleagues. 22 These findings have left uncertainty as to the time frame when ED cardioversion is appropriate, the optimal technique of cardioversion, and the best risk stratification tool to apply in determining treatment approach It is critical to point out that the above reports [20][21][22] and the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial 23 describe patients Values are %, mean (±SD), or n (%, 95% CI) DCCV = direct current cardioversion; dBP = diastolic blood pressure; HR = heart rate; sBP = systolic blood pressure. *Complications at index visit were defined as emesis, nausea requiring antiemetic medications allergic reaction requiring medications, respiratory distress requiring intervention (bag-valve mask, oral airway, noninvasive positive pressure ventilation, intubation), hypotension requiring intravenous fluids or vasoactive agents within 1 hour of initiation of procedural sedation, new bradycardia requiring pharmacologic intervention or pacing within 1 hour of initiation of procedural sedation, unplanned admission, death, or confirmed thromboembolic event.…”

Section: Discussionmentioning

confidence: 99%

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Thirty‐day Outcomes of Emergency Department Patients Undergoing Electrical Cardioversion for Atrial Fibrillation or Flutter

Scheuermeyer

Grafstein

Stenstrom

et al. 2010

Academic Emergency Medicine

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Objectives: While the short-term (<7-day) safety and efficiency of electrical cardioversion for emergency department (ED) patients with atrial fibrillation or flutter have been established, the 30-day outcomes with respect to stroke, thromboembolic events, or death have not been investigated.Methods: A two-center cohort of consecutive ED patients undergoing cardioversion for atrial fibrillation or flutter between January 1, 2000, and September 30, 2007, was retrospectively investigated. This cohort was probabilistically linked with both a regional ED database and the provincial health registry to determine which patients had a subsequent ED visit or hospital admission, stroke, or thromboembolic event or died within 30 days. In addition, trained reviewers performed a detailed chart abstraction on 150 randomly selected patients, with emphasis on demographics, vital signs, medical treatment, and predefined adverse events. Hemodynamically unstable patients or those whose condition was the result of an underlying acute medical diagnosis were excluded. Data were analyzed by descriptive methods.Results: During the study period, 1,233 patients made 1,820 visits for atrial fibrillation or flutter to the ED. Of the 400 eligible patients undergoing direct-current cardioversion (DCCV), no patients died, had a stroke, or had a thromboembolic event in the following 30 days (95% confidence interval [CI] = 0.0 to 0.8% for all outcomes). A total of 141 patients were included in the formal chart review, with five patients (3.5%, 95% CI = 0.5% to 6.6%) failing cardioversion, six patients (4.3%, 95% CI = 0.9% to 7.6%) having a minor adverse event that did not change disposition, and five patients (3.5%, 95% CI = 0.5% to 6.6%) admitted to hospital at the index visit.Conclusions: Cardioversion of patients with atrial fibrillation or flutter in the ED appears to have a very low rate of long-term complications.ACADEMIC EMERGENCY MEDICINE 2010; 17:408-415 ª

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Section: Discussionmentioning

confidence: 99%

“…Of these 96 events, only three occurred in patients with duration of atrial fibrillation less than 48 hours. Weigner and coworkers 20 described only three embolic events in a cohort of 375 patients admitted to a cardiology unit for atrial fibrillation. In this group, 250 patients (66.7%) also had spontaneous conversion to sinus rhythm.…”

Section: Discussionmentioning

confidence: 99%

Thirty‐day Outcomes of Emergency Department Patients Undergoing Electrical Cardioversion for Atrial Fibrillation or Flutter

Scheuermeyer

Grafstein

Stenstrom

et al. 2010

Academic Emergency Medicine

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“…12 It was known that cardioversion of patients with AF of >48 hours duration had a 5-7% risk of stroke without preceding anticoagulation. 12 However, it was also known that 14% of patients with AF of <72 hours duration would have atrial thrombi detectable on transoesophageal echo (TOE). 13 Weigner et al prospectively examined 375 patients admitted with symptomatic AF lasting <48 hours in order to determine the incidence of cardioversion-related clinical thromboembolism.…”

Section: Risk Of Thromboembolism Following Cardioversionwhere Does Thmentioning

confidence: 99%

“…This practice was scrutinised by Weigner et al in 1997. 12 It was known that cardioversion of patients with AF of >48 hours duration had a 5-7% risk of stroke without preceding anticoagulation. 12 However, it was also known that 14% of patients with AF of <72 hours duration would have atrial thrombi detectable on transoesophageal echo (TOE).…”

Section: Risk Of Thromboembolism Following Cardioversionwhere Does Thmentioning

confidence: 99%

Cardioverting acute atrial fibrillation and the risk of thromboembolism: not all patients are created equal

Rankin

2017

Clinical Medicine

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Current guidelines support the well-established clinical practice that patients who present with atrial fi brillation (AF) of less than 48 hours duration should be considered for cardioversion, even in the absence of pre-existing anticoagulation. However, with increasing evidence that short runs of AF confer signifi cant risk of stroke, on what evidence is this 48-hour rule based and is it time to adopt a new approach? We review existing evidence and suggest a novel approach to risk stratifi cation in this setting. Overall, the risk of thromboembolism associated with acute cardioversion of patients with AF that is estimated to be of <48 hours duration is low. However, this risk varies widely depending on patient characteristics. From existing evidence, we show that using the CHA 2 DS 2 -VASc score may allow better selection of appropriate patients in order to prevent exposing specifi c patient groups to an unacceptably high risk of a potentially devastating complication. KEYWORDS : Anticoagulants , atrial fi brillation , cardioversion , electrical cardioversion , stroke , thromboembolism IntroductionInternational guidelines support the well-established clinical practice that patients who present with non-valvular atrial fibrillation (AF) of less than 48 hours duration should be considered for cardioversion, even in the absence of pre-existing anticoagulation.1,2 The risk with more prolonged periods of AF is that restoration of sinus rhythm may precipitate embolism of intra-atrial thrombus causing stroke. However, with increasing evidence that even short runs of AF confer significant risk of stroke, [3][4][5][6] this review examines the evidence supporting the '48-hour rule' and suggests a novel approach to risk stratification in this setting. Search strategy and selection criteriaData for this review were identified by searches of PubMed using combinations of the terms 'atrial fibrillation', 'cardioversion' and 'thromboembolism'. References sourced ABSTRACTCardioverting acute atrial fi brillation and the risk of thromboembolism: not all patients are created equal from relevant articles were also included. Additional references were identified from review of current international guidelines on the management of atrial fibrillation.

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“…There is therefore inconsistency in the current AF guidelines, where the decisions to initiate and continue anticoagulation are independent of AF burden, but thromboembolic risk in the pericardioversion period is thought to remain relatively low for the first 48 hours. 7 This "48-hour rule," where it is acceptable to perform a cardioversion without first excluding a left atrial thrombus via transesophageal echocardiogram in the first 48 hours, however, is based on a relatively small, nonrandomized study, 23 and no randomized controlled trial data exist to definitively support 48 hours as being a "safe" cutoff time period for thrombus formation. In fact, more recent data obtained from patients with pacemakers and ICDs that have the ability to precisely detect short, subclinical, and asymptomatic AF episodes have demonstrated that the risk of thromboembolism in AF begins to increase much earlier than at 48 hours after AF onset (see below).…”

Section: Atrial Fibrillation Burden and Thromboembolic Riskmentioning

confidence: 99%

Tailored Anticoagulation for Thromboembolic Risk Reduction in Paroxysmal Atrial Fibrillation

Matos

Waks

Zimetbaum

2018

J Innov Cardiac Rhythm Manage

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Risk for Clinical Thromboembolism Associated with Conversion to Sinus Rhythm in Patients with Atrial Fibrillation Lasting Less Than 48 Hours

Abstract: Among patients presenting with atrial fibrillation that was clinically estimated to have lasted less than 48 hours, the likelihood of cardioversion-related clinical thromboembolism is low. These data support the current recommendation for early cardioversion in these patients.

Cited by 213 publications

References 0 publications

Thirty‐day Outcomes of Emergency Department Patients Undergoing Electrical Cardioversion for Atrial Fibrillation or Flutter

Thirty‐day Outcomes of Emergency Department Patients Undergoing Electrical Cardioversion for Atrial Fibrillation or Flutter

Cardioverting acute atrial fibrillation and the risk of thromboembolism: not all patients are created equal

Tailored Anticoagulation for Thromboembolic Risk Reduction in Paroxysmal Atrial Fibrillation

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