The Safety of Low-Molecular Weight Heparins for the Prevention of Thromboembolic Events after Cardioversion of Atrial Fibrillation

Abstract

SUMMARYTransesophageal echocardiography (TEE) guided early cardioversion (CV) in conjunction with short-term anticoagulation has been shown to be safe, and an alternative to prolonged conventional anticoagulation therapy. Recently, low molecular weight heparins (LMWHs) have been used successfully as an alternative to standard heparin therapy obviating the need for hospitalization and APTT monitoring. The aim of this study was to determine the feasibility and safety of TEE guided early cardioversion in conjunction with short-term LMWH use in patients with nonvalvular atrial fibrillation (NVAF).The study group consisted of 172 consecutive patients with NVAF. Before TEE, 90 patients received LMWH (Dalteparin 2 × 5,000U) and 82 patients received standard heparin (UFH) (5,000U bolus followed by infusion to raise APTT to 1.5 times control). TEE was performed and the left atrium and left atrial appendage were examined thoroughly for the presence of thrombus. One patient from each group was excluded due to detection of a left atrial thrombus by TEE. Immediately after TEE, CV was attempted and warfarin was initiated. All patients received warfarin for one month after CV. In the LMWH group, 89 of 90 patients (98.9%) were successfully cardioverted. CV was successful in 97.5% of the patients in the UFH group. None of the patients experienced thromboembolic events during the four weeks after CV.TEE guided early CV in conjunction with short-term LMWH treatment is as safe as UFH for the prevention of thromboembolic events after CV. (Jpn Heart J 2003; 44: 369-377)

Low molecular weight heparin (parnaparin) for cardioembolic events prevention in patients with atrial fibrillation undergoing elective electrical cardioversion: a prospective cohort study

“…Approximately half of the patients included in each group underwent electrical CV or medical CV; no thromboembolic events occurred during the 4 weeks following CV. Even though TTE was performed in all patients, and a control group with standard heparin was included, no adjustment of LMWH for patient's weight was performed, and no information about treatment duration before and after CV was provided [22].…”

Stroke Prevention in Patients With Atrial Fibrillation: A Systematic Review Update

“…We identified 220 articles representing 117 studies relevant to KQ 3 (Appendix Table F-3). [23][24][25][26]112,113,115,124,127,134,141,169,177,179,187,188,197, A total of 22 RCTs [23][24][25][26]113,115,215,219,232,233,250,276,288,289,315,320,321,339,354,358,366,371 and 95 observational studies 112,127,141,177,207,208,214,218,220,221,[226][227][228][229][230]238,239,<...>…”

“…[23][24][25][26]113,232,233,288,375 Two studies were unclear or did not report a geographical location. 115,366 Seventy-five studies were considered of good quality or had a low risk of bias rating, 23-26,112,113,115,127,173,177,207,208,214,218,219,228-230,232,233,250,255,258,259,267-269,275,276,287,288,293,294,297,299,300,303-305,310,311,320-322,327,329,330,339,346,347,362,365,366,370,373,376,379-382,387,388,391-393,395,396,398,400-402,405-409 16 were considered fair quality or had a moderate risk of bias rating, 215,289,315,350,354,358,371,375,[383][384][385][386]389,394,397,403 and 26 were of poor quality or had a high risk of bias rating. 141,220,221,226,227,238,239,253,257,262,264,266,273,292,295,298,302,[307][308]…”

Antithrombotic strategies for the management of non-valvular atrial fibrillation

“…Yigit et al studied 172 patients; all of whom received warfarin after cardioversion, in addition to either dalteparin or unfractionated heparin started prior to cardioversion. The authors concluded that TEE-guided cardioversion with dalteparin (n=90) was as safe as TEEguided cardioversion with unfractionated heparin (n=82) for the prevention of thromboembolic events after cardioversion [38]. Bechtold et al investigated the effects of 2Â100 antiXa IU/kg (with a maximum dose of 2Â10,000 anti-Xa IU) of dalteparin for a median of 11 days in 125 AF patients, concluding that simple, well-tolerated, and effective anticoagulation is possible with dalteparin [39].…”