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Amin AN, Kartashov A, Ngai W, Steele K, Rosenthal N. Effectiveness, Safety, and Costs of Thromboprophylaxis with Enoxaparin or Unfractionated Heparin Among Medical Inpatients With Chronic Obstructive Pulmonary Disease or Heart Failure. J Health Econ Outcomes Res 2024; 11:44-56. [PMID: 38390025 PMCID: PMC10883471 DOI: 10.36469/001c.92408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/12/2024] [Indexed: 02/24/2024]
Abstract
Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are risk factors for venous thromboembolism (VTE). Enoxaparin and unfractionated heparin (UFH) help prevent hospital-associated VTE, but few studies have compared them in COPD or HF. Objectives: To compare effectiveness, safety, and costs of enoxaparin vs UFH thromboprophylaxis in medical inpatients with COPD or HF. Methods: This retrospective cohort study included adults with COPD or HF from the Premier PINC AI Healthcare Database. Included patients received prophylactic-dose enoxaparin or UFH during a >6-day index hospitalization (the first visit/admission that met selection criteria during the study period) between January 1, 2010, and September 30, 2016. Multivariable regression models assessed independent associations between exposures and outcomes. Hospital costs were adjusted to 2017 US dollars. Patients were followed 90 days postdischarge (readmission period). Results: In the COPD cohort, 114 174 (69%) patients received enoxaparin and 51 011 (31%) received UFH. Among patients with COPD, enoxaparin recipients had 21%, 37%, and 10% lower odds of VTE, major bleeding, and in-hospital mortality during index admission, and 17% and 50% lower odds of major bleeding and heparin-induced thrombocytopenia (HIT) during the readmission period, compared with UFH recipients (all P <.006). In the HF cohort, 58 488 (58%) patients received enoxaparin and 42 726 (42%) received UFH. Enoxaparin recipients had 24% and 10% lower odds of major bleeding and in-hospital mortality during index admission, and 13%, 11%, and 51% lower odds of VTE, major bleeding, and HIT during readmission (all P <.04) compared with UFH recipients. Enoxaparin recipients also had significantly lower total hospital costs during index admission (mean reduction per patient: COPD, 1280 ; H F , 2677) and readmission (COPD, 379 ; H F , 1024). Among inpatients with COPD or HF, thromboprophylaxis with enoxaparin vs UFH was associated with significantly lower odds of bleeding, mortality, and HIT, and with lower hospital costs. Conclusions: This study suggests that thromboprophylaxis with enoxaparin is associated with better outcomes and lower costs among medical inpatients with COPD or HF based on real-world evidence. Our findings underscore the importance of assessing clinical outcomes and side effects when evaluating cost-effectiveness.
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Affiliation(s)
| | - Alex Kartashov
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
| | | | | | - Ning Rosenthal
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
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Rottura M, Drago SFA, Molonia A, Irrera N, Marino S, Scoglio R, Orlando L, Gigliotti De Fazio M, Squadrito F, Arcoraci V, Imbalzano E. Prescriptive behavior of non-vitamin K oral anticoagulants in patients affected by atrial fibrillation in general practice. Biomed Pharmacother 2023; 165:115020. [PMID: 37352701 DOI: 10.1016/j.biopha.2023.115020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and in recent years the pharmacological approach has been strongly implemented; in Italy, the prescription of the non-vitamin K oral anticoagulants (NOAC) was also extended to General Practitioners (GPs) since 2020. The aim of the present study was to investigate the GPs prescribing behaviour of NOACs. An observational study was performed by using the computerized medical record of 14 GPs in Sicily: patients affected by AF were selected and stratified according to the prescribed antithrombotic drugs. Patients were considered inadequately managed if antithrombotic treatment was not adherent to recent ESC guidelines. A total of 467 (2.7 %) patients were affected by AF, 276 (59.1 %) were treated with an oral anticoagulant (OAC) regardless the high stroke risk (OR 1.64; 95 %CI 0.74-3.62; p = 0.226). The NOAC users were 236 patients as follow: Rivaroxaban 33.5 %, Apixaban 33,1 %, Dabigatran 17,4 %, Edoxaban 16.1 %. In 7 patients an inappropriate NOAC treatment was observed. Among Vitamin-K antagonist users, 25.0 % were considered inappropriate. Patients not treated with OAC were 191, of them 81.7 % were at high stroke risk and did not receive any OAC despite the indication to treat. In addition, the probability to be not properly managed significantly increased in older and in patients with atherosclerosis. Conversely, patients with at least one reported cardiology counselling significantly reduced the likelihood to be not properly managed (OR 0.38, 95 %CI 0.25-0.58; p 0.01). Our results suggest the need to optimize the management of real-life AF patients by improving prescribing adherence to ESC guidelines.
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Affiliation(s)
- M Rottura
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - S F A Drago
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - A Molonia
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - N Irrera
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - S Marino
- Italian Society of General Practice (SIMG), Messina, Italy
| | - R Scoglio
- Italian Society of General Practice (SIMG), Messina, Italy
| | - L Orlando
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - M Gigliotti De Fazio
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - F Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - V Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy.
| | - E Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
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Caldarola P, De Iaco F, Pugliese FR, De Luca L, Fabbri A, Riccio C, Scicchitano P, Vanni S, Di Pasquale G, Gulizia MM, Gabrielli D, Oliva F, Colivicchi F. ANMCO-SIMEU consensus document: appropriate management of atrial fibrillation in the emergency department. Eur Heart J Suppl 2023; 25:D255-D277. [PMID: 37213798 PMCID: PMC10194824 DOI: 10.1093/eurheartjsupp/suad110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Atrial fibrillation (AF) accounts for 2% of the total presentations to the emergency department (ED) and represents the most frequent arrhythmic cause for hospitalization. It steadily increases the risk of thromboembolic events and is often associated with several comorbidities that negatively affect patient's quality of life and prognosis. AF has a considerable impact on healthcare resources, making the promotion of an adequate and coordinated management of this arrhythmia necessary in order to avoid clinical complications and to implement the adoption of appropriate technological and pharmacological treatment options. AF management varies across regions and hospitals and there is also heterogeneity in the use of anticoagulation and electric cardioversion, with limited use of direct oral anticoagulants. The ED represents the first access point for early management of patients with AF. The appropriate management of this arrhythmia in the acute setting has a great impact on improving patient's quality of life and outcomes as well as on rationalization of the financial resources related to the clinical course of AF. Therefore, physicians should provide a well-structured clinical and diagnostic pathway for patients with AF who are admitted to the ED. This should be based on a tight and propositional collaboration among several specialists, i.e. the ED physician, cardiologist, internal medicine physician, anesthesiologist. The aim of this ANMCO-SIMEU consensus document is to provide shared recommendations for promoting an integrated, accurate, and up-to-date management of patients with AF admitted to the ED or Cardiology Department, in order to make it homogeneous across the national territory.
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Affiliation(s)
| | - Fabio De Iaco
- Pronto Soccorso e Medicina d'Urgenza, A.O. Martini, Via Luigi Ferdinando Marsigli, 84 - 10141 Torino (TO), Italy
| | - Francesco Rocco Pugliese
- U.O.C. Medicina e Chirurgia d'Accettazione e d'Urgenza, Ospedale Sandro Pertini, Via dei Monti Tiburtini, 385 - 00157 Roma, Italy
| | - Leonardo De Luca
- U.O.C. di Cardiologia, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Cir.ne Gianicolense, 87 - 00152 Rome, Italy
| | - Andrea Fabbri
- Pronto Soccorso e Medicina d'Urgenza-118, Azienda USL della Romagna, Via Carlo Forlanini, 34 - 47121 Forlì, Italy
| | - Carmine Riccio
- U.O.S.D. Follow up del Paziente Post-Acuto, Dipartimento Cardiovascolare, A.O.R.N. Sant'Anna e San Sebastiano, Via Ferdinando Palasciano, 81100 Caserta, Italy
| | - Pietro Scicchitano
- U.O. Cardiologia-UTIC, Ospedale "F. Perinei", SS96 - 70022 Altamura (BA), Italy
| | - Simone Vanni
- S.O.C. Medicina d'Urgenza, Ospedale San Giuseppe, Empoli (FI) e Direttore Area Formazione, Dipartimento di Emergenza e Area Critica, Azienda USL Toscana Centro, Viale Giovanni Boccaccio, 16/20, 50053 Empoli FI, Italy
| | - Giuseppe Di Pasquale
- Direzione Generale Cura della Persona, Salute e Welfare, Regione Emilia-Romagna, Viale Aldo Moro, 21 - 40127 Bologna, Italy
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Piazza Santa Maria di Gesù, 5 - 95124 Catania, Italy
| | - Domenico Gabrielli
- U.O.C. di Cardiologia, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Cir.ne Gianicolense, 87 - 00152 Rome, Italy
- Fondazione per il Tuo cuore - Heart Care Foundation, Via Alfonso la Marmora, 36- 50121 Firenze, Italy
| | - Fabrizio Oliva
- Cardiologia 1-Emodinamica, Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3 - 20162 Milano, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri - ASL Roma 1, Via Giovanni Martinotti, 20 - 00135 Roma, Italy
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Chyou JY, Barkoudah E, Dukes JW, Goldstein LB, Joglar JA, Lee AM, Lubitz SA, Marill KA, Sneed KB, Streur MM, Wong GC, Gopinathannair R. Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e676-e698. [PMID: 36912134 DOI: 10.1161/cir.0000000000001133] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.
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Briosa e Gala A, Pope MTB, Leo M, Sharp AJ, Tsoi V, Paisey J, Curzen N, Betts TR. 'Pill-in-the-pocket' Oral Anticoagulation Guided by Daily Rhythm Monitoring for Stroke Prevention in Patients with AF: A Systematic Review and Meta-analysis. Arrhythm Electrophysiol Rev 2023; 12:e05. [PMID: 37600156 PMCID: PMC10433111 DOI: 10.15420/aer.2022.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/06/2022] [Indexed: 03/06/2023] Open
Abstract
Aims In patients with a low AF burden and long periods of sinus rhythm, 'pill-in-the-pocket' oral anticoagulation (OAC) may, taken as needed in response to AF episodes, offer the same thromboembolic protection as continuous, life-long OAC, while reducing bleeding complications at the same time. The purpose of this study is to systematically summarise available evidence pertaining to the feasibility, safety and efficacy of pill-in-the-pocket OAC. Methods Medline and Embase were searched from inception to July 2022 for studies adopting a pill-in-the-pocket OAC strategy in AF patients guided by daily rhythm monitoring (PROSPERO/CRD42020209564). Outcomes of interest were extracted and event rates per patient-years of follow-up were calculated. A random effects model was used for pooled estimates. Results Eight studies were included (711 patients). Daily rhythm monitoring was continuous in six studies and intermittent in two (pulse checks or smartphone single-lead electrocardiograms were used). Anticoagulation criteria varied across studies, reflecting the uncertainty regarding the AF burden that warrants anticoagulation. The mean time from AF meeting OAC criteria to its initiation was not reported. Adopting pill-in-the-pocket OAC led to 390 (54.7%) patients stopping OAC, 85 (12.0%) patients taking pill-in-the-pocket OAC and 237 (33.3%) patients remaining on or returning to continuous OAC. Overall, annualised ischaemic stroke and major bleeding rates per patient-year of follow-up were low at 0.005 (95% CI [0.002-0.012]) and 0.024 (95% CI [0.013-0.043]), respectively. Conclusion Current evidence, although encouraging, is insufficient to inform practice. Additional studies are required to improve our understanding of the relationships between AF burden and thromboembolic risk to help define anticoagulation criteria and appropriate monitoring strategies.
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Affiliation(s)
- Andre Briosa e Gala
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael Timothy Brian Pope
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Milena Leo
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alexander James Sharp
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Victor Tsoi
- Wessex Cardiac Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - John Paisey
- Wessex Cardiac Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Southampton, UK
- Wessex Cardiac Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Timothy Rider Betts
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- NIHR Biomedical Research Centre, Oxford, UK
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Marques T, Darrieux F, Gouvêa F, Garambone L, Lindoso AP, Lage J, Sacilotto L, Coimbra AL, Pinheiro M, Olivetti N, Lara S, Hardy C, Athayde G, Hachul D, Pisani C, Wu TC, Scanavacca M. Trombo Atrial Esquerdo e Contraste Espontâneo Denso no Uso de Anticoagulante Oral de Ação Direta em Fibrilação Atrial: Visão de Centro Referenciado. Arq Bras Cardiol 2022; 119:514-519. [PMID: 36169450 PMCID: PMC9563890 DOI: 10.36660/abc.20210658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 04/06/2022] [Indexed: 11/18/2022] Open
Abstract
Fundamento Objetivo Métodos Resultados Conclusão
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Xiong XB, Su YT, Ke HY, Tsai SH, Lai JJ. Female With Progressive Exertional Dyspnea. Ann Emerg Med 2022; 79:527-539. [DOI: 10.1016/j.annemergmed.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Indexed: 11/26/2022]
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Sakhnini A, Carasso S, Znait ZA, Amjad S, Grossman L, Marai I. Does Duration of Symptoms Reliably Predict Detection of Left Atrial Thrombus in Newly Diagnosed Atrial Fibrillation. J Atr Fibrillation 2021; 14:20200481. [PMID: 34950371 DOI: 10.4022/jafib.20200481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/19/2021] [Accepted: 05/20/2021] [Indexed: 11/10/2022]
Abstract
Background Large prospective trials attribute minimal thromboembolic risk for cardioversion of atrial fibrillation (AF) when duration of symptoms is shorter than 48 hours. Our goal is to compare the prevalence of left atrial appendage (LAA) thrombus as demonstrated by a Trans esophageal echocardiography (TEE) exam between patients presenting with less or more than 48 hours of AF symptoms. Methods Observational cohort study including consecutive patients hospitalized with primary diagnosis of new onset AF, not previously treated with oral anticoagulation. All patients underwent TEE to exclude LAA thrombus, regardless of symptoms duration. Patients were divided into two groups based on AF duration: 1) early presenters: up to 48 hours, 2) later presenters: longer than 48 hours. Results The study included 122 patients mean age 65.8 years). The "early presenters" were younger, with less co-morbidities. LAA thrombus was detected in 13(21%) of 62 early presenters, compared to 20 (33%) of 60 patients of the second group (P=0.12). Significant predictors of LAA thrombus in the whole cohort by univariate analysis were ≥65 years of age (1.051, P=0.017), acute heart failure (2.394, P=0.038), and history of coronary artery/ peripheral vascular disease (2.7, P= 0.019). Notably neither duration of symptoms nor CHA2DS2-VASc score significantly predicted LAA thrombus. Inmultivariate analysis, only age ≥65 was found to be a significant predictor of LAA thrombus. Conclusions LAA thrombus in patients presenting within 48 hours of AF symptoms onset is not uncommon. Duration of symptoms is not reliable for excluding LAA thrombus.
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Affiliation(s)
- Ali Sakhnini
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Shemy Carasso
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Zyad Abu Znait
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Shalabi Amjad
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Lisa Grossman
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Ibrahim Marai
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
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Huang CK, Wang JC, Chung CH, Chen SJ, Liao WI, Chien WC. The risk and timing of acute ischemic stroke after electrical cardioversion for atrial fibrillation in Taiwan: A nationwide population-based cohort study. Int J Cardiol 2021; 351:55-60. [PMID: 34954280 DOI: 10.1016/j.ijcard.2021.12.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/11/2021] [Accepted: 12/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a positive association between electrical cardioversion (ECV) and acute ischemic stroke (AIS). Although 4 weeks of anticoagulation therapy after ECV in atrial fibrillation (AF) patients is generally suggested by current guidelines to reduce the risk of AIS, limited studies have been conducted in Asian populations to determine the risk and timing of AIS after ECV for AF in recent years. Therefore, we aim to use the National Health Insurance Research Database (NHIRD) in Taiwan to determine the risk and timing of AIS after ECV for AF. METHODS The data analyzed in this nationwide population-based retrospective cohort study were obtained from the NHIRD in Taiwan. The outcome in this study was the cumulative incidence of AIS in patients with AF during 7-day and 30-day follow-up periods after the patients underwent ECV. RESULTS Our analysis included 39,697 patients with AF, of whom 5723 received ECV and 5723 were propensity score-matched controls. Compared to the controls, patients who received ECV exhibited a significantly increased incidence of 7-day AIS development (adjusted hazard ratio [HR] = 1.524, p = 0.003). In contrast, the incidence of 30-day AIS development showed no significant increase (adjusted HR = 1.301, p = 0.426). CONCLUSIONS AF patients who underwent ECV had a higher incidence of 7-day AIS development but not 30-day AIS development. Considering the timing of AIS development after ECV in AF patients, the optimal duration of antithrombotic therapy after ECV deserves further investigation.
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Affiliation(s)
- Chih-Kang Huang
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jen-Chun Wang
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; School of Public Health, National Defense Medical Center, Taipei, Taiwan; Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan
| | - Sy-Jou Chen
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Combat and Disaster Casualty Care Training Center, National Defense Medical Center, Taipei, Taiwan
| | - Wen-I Liao
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; School of Public Health, National Defense Medical Center, Taipei, Taiwan; Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan.
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Lucà F, Giubilato S, Di Fusco SA, Piccioni L, Rao CM, Iorio A, Cipolletta L, D’Elia E, Gelsomino S, Rossini R, Colivicchi F, Gulizia MM. Anticoagulation in Atrial Fibrillation Cardioversion: What Is Crucial to Take into Account. J Clin Med 2021; 10:jcm10153212. [PMID: 34361996 PMCID: PMC8348761 DOI: 10.3390/jcm10153212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 12/15/2022] Open
Abstract
The therapeutic dilemma between rhythm and rate control in the management of atrial fibrillation (AF) is still unresolved and electrical or pharmacological cardioversion (CV) frequently represents a useful strategy. The most recent guidelines recommend anticoagulation according to individual thromboembolic risk. Vitamin K antagonists (VKAs) have been routinely used to prevent thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) represent a significant advance due to their more predictable therapeutic effect and more favorable hemorrhagic risk profile. In hemodynamically unstable patients, an emergency electrical cardioversion (ECV) must be performed. In this situation, intravenous heparin or low molecular weight heparin (LMWH) should be administered before CV. In patients with AF occurring within less than 48 h, synchronized direct ECV should be the elective procedure, as it restores sinus rhythm quicker and more successfully than pharmacological cardioversion (PCV) and is associated with shorter length of hospitalization. Patients with acute onset AF were traditionally considered at lower risk of thromboembolic events due to the shorter time for atrial thrombus formation. In patients with hemodynamic stability and AF for more than 48 h, an ECV should be planned after at least 3 weeks of anticoagulation therapy. Alternatively, transesophageal echocardiography (TEE) to rule out left atrial appendage thrombus (LAAT) should be performed, followed by ECV and anticoagulation for at least 4 weeks. Theoretically, the standardized use of TEE before CV allows a better stratification of thromboembolic risk, although data available to date are not univocal.
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Affiliation(s)
- Fabiana Lucà
- Division of Cardiology, Big Metropolitan Hospital, Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
- Correspondence: (F.L.); (L.P.)
| | - Simona Giubilato
- Division of Cardiology, Cannizzaro Hospital, 95121 Catania, Italy;
| | | | - Laura Piccioni
- Division of Cardiology, Cardiovascular Departiment, Civile Giuseppe Mazzini Hospital, 64100 Teramo, Italy
- Correspondence: (F.L.); (L.P.)
| | - Carmelo Massimiliano Rao
- Division of Cardiology, Big Metropolitan Hospital, Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
| | - Annamaria Iorio
- Division of Cardiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (A.I.); (E.D.)
| | - Laura Cipolletta
- Division of Cardiology, Department of Cardiovascular Sciences, Ancona University Hospital, 60126 Ancona, Italy;
| | - Emilia D’Elia
- Division of Cardiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (A.I.); (E.D.)
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6202 AZ Maastricht, The Netherlands;
| | - Roberta Rossini
- Division of Cardiology, S. Croce e Carle Hospital, 12100 Cuneo, Italy;
| | - Furio Colivicchi
- Division of Cardiology, S. Filippo Neri Hospital, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Michele Massimo Gulizia
- Division of Cardiology, Garibaldi-Nesima Hospital, 95123 Catania, Italy;
- Heart Care Foundation, 50121 Florence, Italy
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Migliore F, Providencia R, Farkowski MM, Dan GA, Daniel S, Potpara TS, Jubele K, Chun JKR, de Asmundis C, Zorzi A, Boveda S. Antithrombotic treatment management in low stroke risk patients undergoing cardioversion of atrial fibrillation <48 h duration: results of an EHRA survey. Europace 2021; 23:1502-1507. [PMID: 33990842 DOI: 10.1093/europace/euab106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/13/2022] Open
Abstract
Data supporting the safety of cardioversion (CV) of atrial fibrillation (AF) without anticoagulation in patients with AF duration <48 h are scarce. Observational studies suggest that the risk of stroke in these patients is very low when the definite duration of the AF episode is of <48 h and the clinical risk profile as estimated through the CHA2DS2VASc score is low (a score of 0 for men and 1 for women). As the recent 2020 European Society of Cardiology (ESC) guidelines indication for this clinical scenario is based mainly on consensus, we sent out a survey to assess the current clinical practice on anticoagulation prior to and post-CV in patients with AF <24-48 h duration and low stroke risk across centres in Europe. Of the 136 respondents, half were affiliated to university hospitals (68/136; 50%). Non-university hospitals (50/136; 36%) and private hospitals (2/136; 1.4%) accounted over a third of respondents. The main findings of our survey were (i) heterogeneity in the anticoagulation management both before and post-CV in low stroke-risk patients with AF <48 h, (ii) higher utilization of periprocedural low-molecular-weight heparin than of non-vitamin K antagonist oral anticoagulant, (iii) higher utilization of pre-CV transoesophageal echocardiography for electrical CV than for pharmacological CV regardless of the duration of AF, (iv) high adherence to a 4-week post-CV oral anticoagulant (OAC) therapy, mainly for electrical CV, and finally, (v) perceived higher acceptance of lack of post-CV OAC therapy in patients with <24 h than 24-48 h episode duration. The results obtained in this survey highlight the need for more research providing definitive clarification on the safety of CV without anticoagulation in patients with short duration AF.
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Affiliation(s)
- Federico Migliore
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani 2, 35121 Padova, Italy
| | - Rui Providencia
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,Institute of Health Informatics Research, University College of London, London, UK
| | - Michal M Farkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Georghe Andrei Dan
- Carol Davila' University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Scherr Daniel
- Division of Cardiology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Tatjana S Potpara
- Serbia School of Medicine, University of Belgrade, Belgrade, Serbia.,Department for Intensive Care in Cardiac Arrhythmias, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Kristine Jubele
- P.Stradins Clinical University Hospital, Riga Stradins University, Riga, Latvia
| | - Julian K R Chun
- CCB, Cardiology, Med. Klinik III, Markuskrankenhaus Frankfurt, Germany
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani 2, 35121 Padova, Italy
| | - Serge Boveda
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium.,Heart Rhythm Department, Clinique Pasteur, 31076 Toulouse, France
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12
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 4814] [Impact Index Per Article: 1604.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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14
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Hartinger JM, Svobodová A, Malíková I, Šachl R, Slanař O. Effective use of fondaparinux in patient with unresponsiveness to nadroparin. J Clin Pharm Ther 2020; 46:539-542. [PMID: 33277918 DOI: 10.1111/jcpt.13328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/30/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Fondaparinux exhibits a similar mechanism of action as LMWH. Since both of these drugs bind to antithrombin and increase its affinity to factor Xa, fondaparinux is not expected to be an effective alternative anticoagulant to LMWH in case of LMWH resistance. CASE SUMMARY We report on a case of effective anticoagulation using fondaparinux following total unresponsiveness to high doses of nadroparin administered twice daily, as confirmed via repeated anti-Xa measurements. The antithrombin levels were within the normal range. WHAT IS NEW AND CONCLUSION To the best of our knowledge, this is the first report of the effective use of fondaparinux in the case of unresponsiveness to LMWH.
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Affiliation(s)
- Jan Miroslav Hartinger
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Alžběta Svobodová
- II. Surgical Clinic - Cardiovascular Surgery, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ivana Malíková
- Institute of Medical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Robert Šachl
- Department of Anesthesiology and Intensive Care, Institute of Pharmacology, 1st Faculty of Medicine and Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Ondřej Slanař
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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15
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Khatami M, Pope MK, Le Page S, Radic P, Schirripa V, Grundvold I, Atar D. Cardioversion Safety - Are We Doing Enough? Cardiology 2020; 145:740-745. [PMID: 32898849 DOI: 10.1159/000509343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/06/2020] [Indexed: 11/19/2022]
Abstract
There is a considerable periprocedural risk of thromboembolic events in atrial fibrillation patients undergoing cardioversion, and treatment with anticoagulants is therefore a hallmark of cardioversion safety. Based on retrospective subgroup analyses and prospective studies, non-vitamin K anticoagulants are at least as efficient as vitamin K-antagonists in preventing thromboembolic complications after cardioversion. The risk of thromboembolic complications after cardioversion very much depends on the comorbidities in a given patient, and especially heart failure, diabetes, and age >75 years carry a markedly increased risk. Cardioversion has been considered safe within a 48-h time window after onset of atrial fibrillation without prior treatment with anticoagulants, but recent studies have set this practice into question based on e.g. erratic debut assessment of atrial fibrillation. Therefore, a simple and more practical approach is here suggested, where early cardioversion is performed only in hemodynamically unstable patients.
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Affiliation(s)
- Mohsen Khatami
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway,
| | - Marita Knudsen Pope
- Department of Cardiology, Oslo University Hospital, Oslo, Norway.,Department of Internal Medicine, Hamar Hospital, Innlandet Hospital Trust, Hamar, Norway
| | - Sophie Le Page
- Department of Cardiology, Angers University Hospital, Angers, France
| | - Petra Radic
- Department of Cardiology, University Hospital Sisters of Charity, Zagreb, Croatia
| | | | - Irene Grundvold
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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16
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Affiliation(s)
- Benjamin Low
- Foundation Year 1 Doctor, Department of Cardiology, Imperial College Healthcare NHS Trust, London W6 8RF
| | - Mit Shah
- Cardiology Specialist Registrar, Department of Cardiology, Imperial College Healthcare NHS Trust, London
| | - Vanessa Nassour
- Foundation Year 1 Doctor, Department of Cardiology, Imperial College Healthcare NHS Trust, London
| | - Kevin Fox
- Consultant Cardiologist, Department of Cardiology, Imperial College Healthcare NHS Trust, London
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Abstract
Cancer therapy may lead to cardiovascular complications and can promote each aspect of cardiac disease manifestation, such as vascular disease including coronary heart disease, myocardial diseases including heart failure, structural heart diseases including valvular heart diseases, and rhythm disorders. All potential complications of cancer therapy onto the cardiovascular system require imaging for diagnostic workup as well as monitoring of therapy. Transthoracic echocardiography (TTE) is the most frequently used tool for assessment of cardiac function during or after cancer therapy in daily clinical routine. With modern techniques like strain analysis, echocardiography allows to detect a variety of cardiac diseases as caused by cancer therapy even at subclinical stages. For further workup, specific imaging techniques including nuclear imaging are needed in a multimodality imaging approach to in detail characterize the underlying pathophysiology and to improve the management of the patients. Therefore, the field of imaging in cardio-oncology is rapidly growing. This review article will give an overview about existing literature regarding the role of imaging in the diagnostic evaluation and management of therapy in patient with prior or ongoing cancer therapy.
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Affiliation(s)
- Amir Abbas Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christoph Rischpler
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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18
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Wall C, Jankowski T, Naruka V, Mota P. Comparing the delay with different anticoagulants before elective electrical cardioversion for atrial fibrillation/flutter. PLoS One 2019; 14:e0210170. [PMID: 30605492 DOI: 10.1371/journal.pone.0210170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 12/18/2018] [Indexed: 11/19/2022] Open
Abstract
AIMS To assess the impact of the introduction of direct oral anticoagulants upon the outcomes from elective electrical cardioversion for atrial fibrillation. METHODS This is a retrospective comparison of delay to elective cardioversion with different anticoagulants. The data was gathered from a large regional hospital from January 2013 to September 2017. There were 3 measured outcomes: 1) the time in weeks from referral to the date of attempted electrical cardioversion; 2) the proportion of patients who were successfully cardioverted; and 3) the proportion of patients who remained in sinus rhythm by the 12 week follow-up. Time-to-cardioversion was non-parametrically distributed so was analysed with Kruskal-Wallis testing and Mann-Whitney-U testing. Maintenance of sinus rhythm was analysed using z-testing. RESULTS 1,374 patients were submitted to cardioversion. The referrals for cardioversion were either from primary care or from cardiologists. At the time of cardioversion, 789 cases were anticoagulated on warfarin (W), 215 on apixaban (A) and 370 on rivaroxaban (R). All 3 cohorts were initially compared independently using Kruskal-Wallis testing. This demonstrated a significant difference in the delay (measured in weeks) between the A and W group (A = 7, W = 9, P<0.00001); the R and W group (R = 7, W = 9, P<0.00001) and no difference between R and A (A = 7, R = 7, P = 0.92). As there was no difference between the A and R groups, they were combined to form the AR group. The AR group was compared to the W group using Mann-Whitney-U testing which demonstrated a significant delay between the groups (AR = 7, W = 9, P<0.00001). Excluding patients with prior or unknown attempts of cardioversion (n = 791), the W patients (n = 152) were less successful in achieving sinus rhythm at cardioversion than the AR (n = 431) group (W = 95% vs AR = 99% P = 0.04). However at 12 weeks, incidence of sinus rhythm was significantly different (W = 40% vs AR = 49% P = 0.049). These groups were compared by z testing. At 12 weeks' follow-up there was no statistical difference in rate of adverse consequences between the AR group and the W group, but the rate of adverse consequences was too low to draw further conclusions. CONCLUSION DOACs appear to significantly shorten the latency between the decision to cardiovert and the cardioversion procedure by at least 2 weeks compared to warfarin in a real-world setting. In this study, patients who had not previously been cardioverted who were anticoagulated with warfarin had a significantly lower probability of conversion to sinus rhythm and a significantly lower probability to remain in sinus rhythm at the 12 week follow-up compared to the combined apixaban and rivaroxaban group.
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19
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Joung B, Lee JM, Lee KH, Kim TH, Choi EK, Lim WH, Kang KW, Shim J, Lim HE, Park J, Lee SR, Lee YS, Kim JB. 2018 Korean Guideline of Atrial Fibrillation Management. Korean Circ J 2018; 48:1033-1080. [PMID: 30403013 PMCID: PMC6221873 DOI: 10.4070/kcj.2018.0339] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/08/2018] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population. The Korean Heart Rhythm Society organized a Korean AF Management Guideline Committee and analyzed all available studies regarding the management of AF, including studies on Korean patients. This guideline is based on recent data of the Korean population and the recent guidelines of the European Society of Cardiology, European Association for Cardio-Thoracic Surgery, American Heart Association, and Asia Pacific Heart Rhythm Society. Expert consensus or guidelines for the optimal management of Korean patients with AF were achieved after a systematic review with intensive discussion. This article provides general principles for appropriate risk stratification and selection of anticoagulation therapy in Korean patients with AF. This guideline deals with optimal stroke prevention, screening, rate and rhythm control, risk factor management, and integrated management of AF.
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Affiliation(s)
- Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
| | - Jung Myung Lee
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
| | - Ki Hong Lee
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Tae Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
| | - Eue Keun Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ki Woon Kang
- Division of Cardiology, Eulji University College of Medicine, Daejeon, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hong Euy Lim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Junbeom Park
- Department of Cardiology, Ewha Woman University, Seoul, Korea
| | - So Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Soon Chun Hyang University Hospital, Seoul, Korea
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University, Daegu, Korea
| | - Jin Bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
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20
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Warden BA, MacKay J, Jafari M, Willman A, Stecker EC. Use of Direct Oral Anticoagulants Among Patients Undergoing Cardioversion: The Importance of Timing Before Cardioversion. J Am Heart Assoc 2018; 7:e010854. [PMID: 30571504 PMCID: PMC6404444 DOI: 10.1161/jaha.118.010854] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Bruce A Warden
- 1 Department of Pharmacy Oregon Health & Science University Portland OR
| | - John MacKay
- 1 Department of Pharmacy Oregon Health & Science University Portland OR
| | - Melika Jafari
- 1 Department of Pharmacy Oregon Health & Science University Portland OR
| | - Alana Willman
- 1 Department of Pharmacy Oregon Health & Science University Portland OR
| | - Eric C Stecker
- 2 Knight Cardiovascular Institute Oregon Health & Science University Portland OR
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Abstract
BACKGROUND Four non-vitamin-K-antagonist oral anticoagulants (NOACs) have been approved for use in various cardiovascular indications. The direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban are now increasingly used in clinical practice. For some of these agents, available data from real-world studies support the efficacy and safety data in phase III clinical trials. OBJECTIVES This review aims to summarize the current status of trials and observational studies of oral anticoagulant use over the spectrum of cardiovascular disorders (excluding venous thrombosis), provide a reference source beyond stroke prevention for atrial fibrillation (AF) and examine the potential for novel applications in the cardiovascular field. METHODS We searched the recent literature for data on completed and upcoming trials of oral anticoagulants with a particular focus on rivaroxaban. RESULTS Recent data in specific patient subgroups, such as patients with AF undergoing catheter ablation or cardioversion, have led to an extended approval for rivaroxaban, whereas the other NOACs have ongoing or recently completed trials in this setting. However, there are unmet medical needs for several arterial thromboembolic-related conditions, including patients with: AF and acute coronary syndrome, AF and coronary artery disease undergoing elective percutaneous coronary intervention, coronary artery disease and peripheral artery disease, implanted cardiac devices, and embolic stroke of unknown source. CONCLUSION NOACs may provide alternative treatment options in areas of unmet need, and numerous studies are underway to assess their benefit-risk profiles in these settings.
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Affiliation(s)
- A John Camm
- a Cardiovascular and Cell Sciences Research Institute , St George's, University of London and Imperial College , London , UK
| | - Keith A A Fox
- b Centre for Cardiovascular Science , University of Edinburgh and Royal Infirmary of Edinburgh , Edinburgh , UK
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22
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Papp J, Zima E, Bover R, Karaliute R, Rossi A, Szymanski C, Troccoli R, Schneider J, Fagerland MW, Camm AJ, Atar D. Changes in oral anticoagulation for elective cardioversion: results from a European cardioversion registry. Eur Heart J Cardiovasc Pharmacother 2018; 3:147-150. [PMID: 28329309 PMCID: PMC5843131 DOI: 10.1093/ehjcvp/pvx003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 03/09/2017] [Indexed: 12/21/2022]
Abstract
Aims In patients with atrial fibrillation (AF) pharmacological or electrical cardioversion may be performed to restore sinus rhythm. The procedure is associated with an increased risk of thromboembolic events, which can be significantly reduced by adequate anticoagulation (OAC). Our aim was to create a partly prospective, partly retrospective cardioversion registry, particularly focusing on OAC strategies in different European countries, and on emerging choice of OAC over time. Methods From September 2014 to October 2015, cardioversions due to AF performed in six European city hospitals in five European countries (Hungary: Budapest-1 and -2; Italy: Bari and Pisa; France: Amiens; Spain: Madrid; and Lithuania: Kaunas) were recorded in the registry. Results A total of 1101 patients (retrospective/prospective: 679/422, male/female: 742/359, mean age: 67.3 years ± 11.2) were registered. Most of the cardioversions were electrical (97%). Oral anticoagulants were administered in 87% of the patient, the usage of non-VKA oral anticoagulants (NOACs) vs Vitamin K antagonists (VKA) was 31.5% vs 68.5%, respectively. Seventy seven percent of the patients were given oral anticoagulants more than 3 weeks prior to the procedure, and 86% more than 4 weeks after the procedure. When using VKA, international normalized ratio (INR) at cardioversion was above 2.0 in 76% of the cases. A decline in VKA usage (P = 0.033) in elective cardioversion over approximately 1 year was observed. During the observation period, there was an increase in apixaban (P < 0.001), a slight increase in rivaroxaban (P = 0.028) and no changes in dabigatran (P = 0.34) usage for elective cardioversion. There were differences in use of OAC between the countries: Spain used most VKA (89%), while France used least VKA (39%, P < 0.001). Conclusion According to current AF guidelines, NOACs are adequate alternatives to VKA for thromboembolic prevention in AF patients undergoing elective cardioversion. Our results indicate that NOAC use is increasing and there is a significant decrease in VKA use.
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Affiliation(s)
- Judit Papp
- Department of Cardiology, Medical Center Hungarian Defence Forces, 44 Robert Karoly Krt., 1134 Budapest, Hungary
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, 68 Varosmajor u., 1122 Budapest, Hungary
| | - Ramon Bover
- Cardiology Department, University Hospital Clinico San Carlos, Profesor Martin Lagos s/n, 28040 Madrid, Spain
| | - Rasa Karaliute
- Lithuanian University of Health Sciences, Cardiology Clinic, 2 Eiveniu str., 50161 Kaunas, Lithuania
| | - Andrea Rossi
- Cardiothoracic Department, Tuscany Foundation Gabriele Monasterio, 1 Via G. Moruzzi, 56124 Pisa, Italy
| | - Catherine Szymanski
- Cardiology Department, Amiens University Hospital, Avenue Rene Laennec, 80000 Salouel Amiens, France
| | - Rossella Troccoli
- Cardiologia Ospedaliera Polyclinic of Bari, 11 Piazza Giulio Cesare, 70124 Bari, Italy
| | | | - Morten Wang Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
| | - A John Camm
- Molecular and Clinical Research Institute and Cardiology Clinical Academic Group, St. George's University of London and Imperial College, London SW17 0RE, UK
| | - Dan Atar
- Cardiology Department B and Faculty of Medicine, Oslo University Hospital, University of Oslo, 166 Kirkeveien, Building 3-A, 0407 Oslo, Norway
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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Abstract
In this manuscript, we discuss the most important changes in the field of anticoagulant treatment in patients with atrial fibrillation in the setting of electrical cardioversion or catheter ablation. Moreover, we provide practical guidance as well as information on daily practice.
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Affiliation(s)
- S. P. G. van Vugt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M. A. Brouwer
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
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Kang KW, Shim J, Ahn J, Lee DI, Kim J, Joung B, Choi KJ. 2018 Korean Heart Rhythm Society Guidelines for Antiarrhythmic Drug Therapy in Non-valvular Atrial Fibrillation. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Kiviniemi T, Malmberg M, Biancari F, Hartikainen J, Ihlberg L, Yannopoulos F, Riekkinen T, von Hellens O, Lehto J, Nissinen M, Airaksinen KJ, Nieminen T. Thromboembolisms related to post-operative electrical cardioversions for atrial fibrillation in patients with surgical aortic valve replacement. Eur Heart J Qual Care Clin Outcomes 2018; 4:120-125. [PMID: 29390053 DOI: 10.1093/ehjqcco/qcy003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/24/2018] [Indexed: 11/14/2022]
Abstract
Aims Post-operative atrial fibrillation (POAF) is a frequent complication after open-heart surgery, and cardioversions (CV) are commonly performed to restore sinus rhythm. However, little data exists on thrombo-embolic risk related to early post-operative CV and on the recurrence of POAF after CV. CAREAVR study sought to assess the rate of strokes, transient ischaemic attacks (TIA), and mortality shortly after POAF-triggered CV in patients who underwent isolated surgical aortic valve replacement (SAVR) with a bioprosthesis. Methods and results Altogether 721 patients underwent isolated SAVR with a bioprosthesis at four Finnish university hospitals. During post-operative hospitalization, after patients with prior chronic AF were excluded, 309/634 (48.7%) of patients had at least one episode of POAF [median time (interquartile range) 3 (3) days], and an electrical CV was performed in 113/309 (36.6%) of them. The length of hospital stay was not affected by CV. At 30 days follow-up, the rate of stroke, TIA or mortality was higher in those AF patients who underwent CV vs. those who did not (9.7% vs. 3.6%, P = 0.04, respectively; adjusted hazard ratio 2.63, 95% confidence interval 1.00-6.92, P = 0.05). Similar proportion of patients in both groups were in AF rhythm at discharge (32.7% vs. 35.7%, P = 0.18); and at 3 months (25.0% vs. 23.6%, P = 0.40), respectively. Conclusion In this real-world population of patients undergoing isolated SAVR, the rate of POAF was nearly 50%. One-third of these patients underwent an electrical CV, and they exhibited over two-fold risk for thromboembolisms and mortality. Cardioversion did not affect the short-term prevalence of AF.
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Affiliation(s)
- Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, 20521 Turku, Finland
| | - Markus Malmberg
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, 20521 Turku, Finland
| | - Fausto Biancari
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, 20521 Turku, Finland.,Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Leo Ihlberg
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Internal Medicine, Helsinki, Finland.,South Karelia Central Hospital, Internal Medicine, Lappeenranta, Finland
| | - Fredrik Yannopoulos
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Teemu Riekkinen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Otto von Hellens
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Internal Medicine, Helsinki, Finland.,South Karelia Central Hospital, Internal Medicine, Lappeenranta, Finland
| | - Joonas Lehto
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, 20521 Turku, Finland
| | - Maunu Nissinen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Ke Juhani Airaksinen
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, 20521 Turku, Finland
| | - Tuomo Nieminen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Internal Medicine, Helsinki, Finland.,South Karelia Central Hospital, Internal Medicine, Lappeenranta, Finland
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27
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Cappato R, Welsh R. Exploring unmet needs in venous and arterial thromboembolism with rivaroxaban. Thromb Haemost 2017; 116:S2-S12. [DOI: 10.1160/th16-06-0484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/10/2016] [Indexed: 11/05/2022]
Abstract
SummaryThe vast clinical research programme for the direct, oral factor Xa inhibitor rivaroxaban has generated a wealth of data since the first rivaroxaban approval in 2008 for the prevention of venous thrombo embolism (VTE) in patients undergoing elective hip or knee replacement surgery. While rivaroxaban is widely used across a spectrum of seven indications, there is continuous commitment to investigating its wider benefits in new indications and attempts to refine current evidence. Key data from recently completed randomised controlled trials (RCTs) have shown that rivaroxaban is a feasible anticoagulation option for patients with non-valvular atrial fibrillation (NVAF) undergoing cardioversion or catheter ablation. Now, a number of Phase II and III RCTs are underway that seek to uncover further roles for rivaroxaban in patients at risk of thrombosis and aim to improve quality of life. This article will introduce and provide context for these RCTs in the contemporary management of arterial and venous thromboembolism in the following underserved areas: Patients with both NVAF and acute coronary syndrome (ACS) requiring percutaneous coronary intervention (PCI); patients with embolic stroke of undetermined source (ESUS); patients who require transcatheter aortic valve replacement (TAVR); patients with acute or chronic coronary artery disease (CAD; including those with heart failure [HF]); those at risk of or suffering from cancer-associated thrombosis (CAT) and those requiring long-term anticoagulation. It is hoped that this collection of studies provides clarity around the use of rivaroxaban as a fundamental component of antithrombotic therapy in an array of clinical situations.
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28
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Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen S, Lip GYH, Morais J, Rasmussen L, Siegbahn A, Verheugt FWA, Weitz JI, De Caterina R. Parenteral anticoagulants in heart disease: Current status and perspectives (Section II). Thromb Haemost 2017; 109:769-86. [DOI: 10.1160/th12-06-0403] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 12/25/2012] [Indexed: 11/05/2022]
Abstract
SummaryAnticoagulants are a mainstay of cardiovascular therapy, and parenteral anticoagulants have widespread use in cardiology, especially in acute situations. Parenteral anticoagulants include unfractionated heparin, low-molecular-weight heparins, the synthetic pentasaccharides fondaparinux, idraparinux and idrabiotaparinux, and parenteral direct thrombin inhibitors. The several shortcomings of unfractionated heparin and of low-molecular-weight heparins have prompted the development of the other newer agents. Here we review the mechanisms of action, pharmacological properties and side effects of parenteral anticoagulants used in the management of coronary heart disease treated with or without percutaneous coronary interventions, cardioversion for atrial fibrillation, and prosthetic heart valves and valve repair. Using an evidence-based approach, we describe the results of completed clinical trials, highlight ongoing research with currently available agents, and recommend therapeutic options for specific heart diseases.
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29
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Ţînţ D, Petriş AO, Pop I, Melnic R, Ignat AM, Rogozea LM. Vitamin K Antagonists Versus Novel Oral Anticoagulants for Elective Electrical Cardioversion of Atrial Fibrillation. Am J Ther 2017; 24:e553-e558. [DOI: 10.1097/mjt.0000000000000590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Calvo J. Low-molecular-weight heparins in patients with atrial fibrillation. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2016.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Calvo Romero J. Heparinas de bajo peso molecular en pacientes con fibrilación auricular. Rev Clin Esp 2017; 217:151-154. [DOI: 10.1016/j.rce.2016.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 09/08/2016] [Accepted: 09/15/2016] [Indexed: 11/17/2022]
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32
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Bonou M, Toutouzas K, Diamantopoulos P, Viniou N, Barbetseas J, Benetos G. Advances in anticoagulation management of patients undergoing cardioversion of nonvalvular atrial fibrillation. Hamostaseologie 2017; 37:277-285. [DOI: 10.5482/hamo-16-07-0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 02/01/2017] [Indexed: 11/05/2022] Open
Abstract
SummaryAtrial fibrillation (AF) is a major cause of stroke. The restoration of sinus rhythm through cardioversion, either chemical or electrical is a common practice. Interestingly, there is an incremental increase from the baseline risk for embolisation in the immediate post-cardioversion period, with most events occurring within 10 days from cardioversion. Especially patients with recent onset AF show the lowest rates of antithrombotic therapy, while having a high stroke risk. Despite the increased risk for embolisation, anticoagulation in patients undergoing cardioversion of atrial fibrillation is often inadequate. Moreover, since the implementation of non-vitamin K antagonists oral anticoagulants (DOACs) there are several therapeutic approaches for pericardioversion anticoagulant therapy and not all suits to all patients. In addition, the extensive use of transesophageal echocardiography provides an alternative strategy, especially useful for patients of high haemorrhagic risk. In this review article, we aim to provide an update on the anticoagulation strategies for patients undergoing cardioversion of non-valvular atrial fibrillation in the advent of the use of DOACs.
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33
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Goette A, Heidbuchel H. Practical Implementation of Anticoagulation Strategy for Patients Undergoing Cardioversion of Atrial Fibrillation. Arrhythm Electrophysiol Rev 2017; 6:50-54. [PMID: 28835835 DOI: 10.15420/aer.2017:3:2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Anticoagulation is routinely prescribed to patients with persistent AF before cardioversion to reduce the risk of thromboembolic events. As direct oral anticoagulants (DOACs) have a rapid onset of action, a consistent anticoagulant effect, if taken correctly, and do not need monitoring or dose adjustments, there is considerable interest in their use for patients with AF undergoing cardioversion. Post-hoc analyses show that DOACs are safe to use prior to and following cardioversion. In addition, two randomised controlled trials, X-VeRT and ENSURE-AF, have demonstrated the efficacy and safety of the DOACs rivaroxaban and edoxaban, respectively, in this setting. The use of DOACs allows cardioversions to be performed promptly and reduces the number of cancelled procedures compared with the use of warfarin.
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Affiliation(s)
| | - Hein Heidbuchel
- Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
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34
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Abstract
Cardiac tachyarrhythmias are encountered commonly during the perioperative period and need to be promptly identified and appropriately managed by the anaesthesiologist. This review intends to highlight important aspects of these tachyarrhythmias and explore a temporal relationship between common medications employed in the perioperative period and their causation. Mechanisms of initiation of tachyarrhythmias, drugs that can trigger those, as well as their diagnosis and management, are also parts of the current review. Cardiac tachyarrhythmias may not always require treatment, and sometimes, aggressive management can trigger more serious types of arrhythmias. A thorough understanding of these tachyarrhythmias and their pathogenesis enables adopting a more objective approach, eschewing risks of inappropriate or unnecessary management strategies. We performed a MEDLINE search using combinations of MeSH terms such as ‘cardiac’, ‘arrhythmias’, ‘anaesthesia’, ‘perioperative’, ‘tachyarrhythmias’ and ‘anaesthetic implications’. We reviewed the relevant publications with regard to cardiac tachyarrhythmias occurring in the perioperative period.
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Affiliation(s)
- Satyen Parida
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
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35
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Andò G, Trio O. New oral anticoagulants versus Warfarin in patients undergoing cardioversion of atrial fibrillation. Int J Cardiol 2016; 225:244-246. [DOI: 10.1016/j.ijcard.2016.09.126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 09/30/2016] [Indexed: 11/25/2022]
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36
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4675] [Impact Index Per Article: 584.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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37
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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38
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Chandola R, Buchholz H, Macarthur R. Long-term use of low-molecular-weight heparin in a patient with Heartware BIVAD (HVAD) with underlying sustained ventricular fibrillation. J Cardiol Cases 2016; 14:171-173. [PMID: 30546687 DOI: 10.1016/j.jccase.2016.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 07/15/2016] [Accepted: 08/04/2016] [Indexed: 11/29/2022] Open
Abstract
We report the case of a 59-year-old patient with Heartware (Framingham, MA, USA) biventricular assist device (BIVAD) implantation who had long-term sustained ventricular fibrillation and was managed on low-molecular-weight heparin for up to two years without any adverse events. The successful outcome in this case provides a clue that the long-term management of Heartware BIVADs with low-molecular-weight heparins could be a viable option even in patients with underlying malignant arrhythmias. <Learning objective: Long-term management of Heartware biventricular assist devices (BIVADs) using low-molecular-weight heparin is possible. This treatment strategy can serve as an alternative to oral anticoagulants in a select group of patients. This case report also suggests that BIVADs can potentially serve as a useful alternative to total artificial heart.>.
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Affiliation(s)
- Rahul Chandola
- Division of Cardiovascular Surgery, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Holger Buchholz
- Division of Cardiovascular Surgery, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Roderick Macarthur
- Division of Cardiovascular Surgery, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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39
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1305] [Impact Index Per Article: 163.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
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40
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Shibata N, Morishima I, Okumura K, Morita Y, Takagi K, Yoshida R, Nagai H, Tomomatsu T, Ikai Y, Terada K, Tsuzuki K, Tsuboi H, Sone T, Murohara T. Non-vitamin K antagonist oral anticoagulants versus warfarin for cardioversion of atrial fibrillation in clinical practice: A single-center experience. J Arrhythm 2016; 33:7-11. [PMID: 28217222 PMCID: PMC5300843 DOI: 10.1016/j.joa.2016.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/06/2016] [Accepted: 04/14/2016] [Indexed: 12/01/2022] Open
Abstract
Background Anticoagulation therapy with the vitamin K antagonist (VKA) warfarin has been demonstrated to reduce thromboembolic risk after electrical cardioversion (ECV). However, data concerning ECV with non-VKA oral anticoagulants (NOACs) is limited. The objective of this study was to determine the efficacy and safety of NOACs in patients undergoing ECV in a real-world clinical practice at a single center in Japan. Methods We retrospectively analyzed the data of 406 consecutive patients who underwent ECV for atrial fibrillation (AF) or flutter under anticoagulation with one of the three NOACs (n=149) or with a VKA (n=257). Results The CHADS2 and HAS-BLED scores were significantly higher in the VKA group, whereas the NOACs group had a tendency toward greater spontaneous echo contrast grades. After ECV, ischemic stroke occurred in three patients of the VKA group and one patient in the NOAC group, all of whom had persistent AF, indicating no significant difference in the thromboembolic event rate within 30 days following ECV. No other thromboembolic events, major bleeding, or death occurred in either group. Among the NOAC and VKA patients in whom we newly introduced an oral anticoagulant to perform ECV, the number of days leading to ECV was significantly lesser for the NOAC patients. Conclusion NOACs may be used as an alternative to VKAs for ECV and may allow prompt ECV in clinical practices.
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Affiliation(s)
- Naoki Shibata
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kenji Okumura
- Department of Cardiology, Tohno Kosei Hospital, Mizunami, Japan
| | - Yasuhiro Morita
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kensuke Takagi
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Ruka Yoshida
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Hiroaki Nagai
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | | | - Yoshihiro Ikai
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kazushi Terada
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kazuhito Tsuzuki
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Hideyuki Tsuboi
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Takahito Sone
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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41
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Peacock WF, Rafique Z, Singer AJ. Direct-Acting Oral Anticoagulants: Practical Considerations for Emergency Medicine Physicians. Emerg Med Int 2016; 2016:1781684. [PMID: 27293895 DOI: 10.1155/2016/1781684] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/11/2016] [Accepted: 03/29/2016] [Indexed: 01/01/2023] Open
Abstract
Nonvalvular atrial fibrillation- (NVAF-) related stroke and venous thromboembolism (VTE) are cardiovascular diseases associated with significant morbidity and economic burden. The historical standard treatment of VTE has been the administration of parenteral heparinoid until oral warfarin therapy attains a therapeutic international normalized ratio. Warfarin has been the most common medication for stroke prevention in NVAF. Warfarin use is complicated by a narrow therapeutic window, unpredictable dose response, numerous food and drug interactions, and requirements for frequent monitoring. To overcome these disadvantages, direct-acting oral anticoagulants (DOACs)—dabigatran, rivaroxaban, apixaban, and edoxaban—have been developed for the prevention of stroke or systemic embolic events (SEE) in patients with NVAF and for the treatment of VTE. Advantages of DOACs include predictable pharmacokinetics, few drug-drug interactions, and low monitoring requirements. In clinical studies, DOACs are noninferior to warfarin for the prevention of NVAF-related stroke and the treatment and prevention of VTE as well as postoperative knee and hip surgery VTE prophylaxis, with decreased bleeding risks. This review addresses the practical considerations for the emergency physician in DOAC use, including dosing recommendations, laboratory monitoring, anticoagulation reversal, and cost-effectiveness. The challenges of DOACs, such as the lack of specific laboratory measurements and antidotes, are also discussed.
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42
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Grönberg T, Hartikainen JEK, Nuotio I, Biancari F, Ylitalo A, Airaksinen KEJ. Anticoagulation, CHA2DS2VASc Score, and Thromboembolic Risk of Cardioversion of Acute Atrial Fibrillation (from the FinCV Study). Am J Cardiol 2016; 117:1294-8. [PMID: 26892448 DOI: 10.1016/j.amjcard.2016.01.024] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/19/2016] [Accepted: 01/19/2016] [Indexed: 11/18/2022]
Abstract
The efficacy of the anticoagulation in preventing thromboembolic complications (TEC) and the usefulness of the CHA2DS2VASc score for assessing stroke risk during cardioversion of acute atrial fibrillation (AF) are unclear. Thus, our objectives were to assess the ability of the CHA2DS2VASc score to predict TEC and to evaluate the efficacy of anticoagulation in the prevention of TEC in Finnish CardioVersion (FinCV) study. The FinCV is a retrospective, multicenter study of 3,143 patients, who underwent 7,660 cardioversions for acute AF. The value of the CHA2DS2VASc score in predicting TEC was analyzed separately in cardioversions performed without and with anticoagulation. A total of 40 definite TEC (0.6%) occurred after 7,237 successful cardioversions and 1 stroke (0.2%) after 423 unsuccessful procedures. In 5,362 cardioversions performed without anticoagulation, the risk of definite TEC increased significantly from 0.4% in patients with a CHA2DS2VASc score of 0 to 1 to 2.3% in those with score of ≥5 (p <0.001 for trend). The C-statistic of the CHA2DS2VASc score was 0.72 (0.61 to 0.83) in predicting definite TEC in non-anticoagulated patients with first cardioversion. The incidence of definite TEC was significantly lower in 2,298 cardioversions performed during anticoagulation (0.1% vs 0.7%, p = 0.001), and the preventive effect of anticoagulation was significant in patients with a score of ≥2 (0.2% vs 1.1%, p = 0.001). In conclusion, CHA2DS2VASc score is a strong predictor of TEC in cardioversion of acute AF performed without anticoagulation. Importantly, periprocedural anticoagulation reduced the risk of TEC by 82%. The overall risk of these complications was low after failed cardioversion.
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Affiliation(s)
| | | | - Ilpo Nuotio
- Division of Medicine, Department of Acute Internal Medicine, Turku University Hospital, Turku, Finland
| | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Antti Ylitalo
- Heart Center, University of Turku and Turku University Hospital, Turku, Finland; Satakunta Central Hospital, Pori, Finland
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Abstract
Transesophageal echocardiography (TEE) plays an important role in atrial fibrillation (AF), mainly to detect the presence of left atrial appendage (LAA) thrombus. It is useful in direct current cardioversion (DCC) guidance and for AF ablation and LAA occlusion. With the increasing number of patients affected by AF, the use of TEE will grow and become an important screening modality for LAA thrombus. Future direction includes broader multi-institutional use; further tools to risk stratify patients; and the use of a new spectrum of oral anticoagulants and their cost-effectiveness in patients with AF undergoing DCC, AF ablation, and LAA occlusion.
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Affiliation(s)
- Teerapat Yingchoncharoen
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA
| | - Saurabh Jha
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA
| | - Allan L Klein
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA.
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Klein HH, Trappe HJ. Cardioversion in Non-Valvular Atrial Fibrillation. Dtsch Arztebl Int 2015; 112:856-62. [PMID: 26763380 DOI: 10.3238/arztebl.2015.0856] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/01/2015] [Accepted: 06/01/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Atrial fibrillation is the most common type of cardiac arrhythmia and is associated with elevated rates of stroke, heart failure, hospital admission, and death. Its prevalence in the overall population is 1.5% to 2%. To convert atrial fibrillation to sinus rhythm, cardioversion is needed. METHODS This review is based on pertinent articles published from 2004 to December 2014 that were retrieved by a selective PubMed search employing the terms "atrial fibrillation" and "cardioversion." RESULTS In electrical cardioversion, a defibrillator is used to pass a pulse of current between two electrodes. In pharmacological cardioversion, antiarrhythmic drugs are given intravenously or orally. Electrical cardioversion results in sinus rhythm in more than 85% of patients; pharmacological cardioversion results in sinus rhythm in about 70% of patients with recent-onset atrial fibrillation. As a rule, cardioversion should be carried out only under effective therapeutic anticoagulation with heparin, a vitamin K antagonist, or a new oral anticoagulant drug. If atrial fibrillation has been present for more than 48 hours, cardioversion must be preceded by transesophageal echocardiography to rule out blood clot in the left atrium, or else the patient is pretreated with an anticoagulant drug for at least 3 weeks. As cardioversion can transiently impair left atrial pumping function, anticoagulation is usually maintained for 4 weeks after the procedure. The decision whether to continue anticoagulation beyond this point is based on the risk of stroke, as assessed with the CHA2DS2-VASc score. CONCLUSION The main risks of cardioversion-thrombo--embolism and clinically significant hemorrhage--occur in 1% of cases or less (in the first 30 days after treatment) if the procedure is carried out as recommended in therapeutic guidelines. Serious complications still occur, but they are rare.
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Airaksinen KJ. Cardioversion Of Atrial Fibrillation And Oral Anticoagulation. J Atr Fibrillation 2015; 8:1260. [PMID: 27957205 DOI: 10.4022/jafib.1260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 08/04/2015] [Accepted: 08/24/2015] [Indexed: 01/22/2023]
Abstract
The risk of thromboembolic events is a major concern in cardioversion of atrial fibrillation. The vast majority of these events occur in the first week following cardioversion. Processes promoting thrombus formation occur early and thrombus may appear in the left atrium within 48 hours of atrial fibrillation. The risk of thromboembolic events also increases with the presence of stroke risk factors. Thus, the current guidelines recommend that also patients with acute atrial fibrillation should undergo cardioversion under cover of unfractionated or low-molecular weight heparin followed by oral anticoagulation for at least 4 weeks in patients at moderate-to-high risk for stroke. Delay of cardioversion < 12 hours from the symptom onset seems to cause a marked increase in the risk of stroke. Thus, short term anticoagulation should be considered also for patients with a low CHA2DS2VASc score if the delay to cardioversion is 12-48 hours.
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Pallisgaard JL, Lindhardt TB, Hansen ML, Schjerning AM, Olesen JB, Staerk L, Torp-Pedersen C, Gislason GH. Cardioversion and Risk of Adverse Events with Dabigatran versus Warfarin-A Nationwide Cohort Study. PLoS One 2015; 10:e0141377. [PMID: 26513589 DOI: 10.1371/journal.pone.0141377] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 10/06/2015] [Indexed: 12/03/2022] Open
Abstract
Aim Cardioversion can rapidly and effectively restore sinus rhythm in patients with persistent atrial fibrillation. Since 2011 dabigatran has been available as an alternative to warfarin to prevent thromboembolic events in patients with non-valvular atrial fibrillation undergoing cardioversion. We studied time to cardioversion, risk of adverse events, and risk of readmission with atrial fibrillation after cardioversion according to anticoagulation therapy. Methods and Results Through the nationwide Danish registries we included 1,230 oral anticoagulation naïve patients with first time non-valvular atrial fibrillation and first time cardioversion from 2011 to 2012; 37% in the dabigatran group (n = 456), and 63% in the warfarin group (n = 774). Median time to cardioversion was 4.0 (interquartile range [IQR] 2.9 to 6.5) and 6.9 (IQR 3.9 to 12.1) weeks in the dabigatran and warfarin groups respectively, and the adjusted odds ratio of cardioversion within the first 4 weeks was 2.3 (95% confidence interval [CI] 1.7 to 3.1) in favor of dabigatran. The cumulative incidence of composite endpoint of stroke, bleeding or death were 2.0% and 1.0% at 30 weeks in the warfarin and dabigatran groups respectively, with an adjusted hazard ratio of 1.33 (95% CI 0.33 to 5.42). Cumulative incidence of readmission with atrial fibrillation after 30 weeks were 9% and 11% in the warfarin and dabigatran groups, respectively, and an adjusted hazard ratio of 0.66 (95% CI 0.41 to 1.08). Conclusion Anticoagulation treatment with dabigatran allows shorter time to cardioversion for atrial fibrillation than warfarin, and appears to be an effective and safe alternative treatment strategy to warfarin.
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Hohnloser SH, Cappato R, Ezekowitz MD, Evers T, Sahin K, Kirchhof P, Meng IL, van Eickels M, Camm AJ. Patient-reported treatment satisfaction and budget impact with rivaroxaban vs. standard therapy in elective cardioversion of atrial fibrillation: a post hoc analysis of the X-VeRT trial. Europace 2015; 18:184-90. [PMID: 26487668 PMCID: PMC4767121 DOI: 10.1093/europace/euv294] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 08/03/2015] [Indexed: 11/23/2022] Open
Abstract
Aims We compared patient-reported treatment satisfaction and the economic impact of anticoagulation therapy with rivaroxaban vs. vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation undergoing elective cardioversion procedures. Methods and results The current study is a post hoc analysis of the prospective, multicentre X-VeRT (EXplore the efficacy and safety of once-daily oral riVaroxaban for the prevention of caRdiovascular events in subjects with non-valvular aTrial fibrillation scheduled for cardioversion) trial. Patient-reported treatment satisfaction with anticoagulation therapy was assessed using the Treatment Satisfaction Questionnaire for Medication version II in seven countries (US, UK, Canada, Germany, France, Italy, and the Netherlands). An economic model was also developed to estimate the impact of postponed cardioversions for two countries (UK and Italy). This model estimated the total costs of cardioversion, taking into consideration the costs for drug therapy (including extended treatment duration due to cardioversion postponement), international normalized ratio monitoring of VKAs, the cardioversion procedure, and rescheduling the procedure. These costs were linked to the respective X-VeRT study data to estimate the total costs. Patients receiving rivaroxaban in the delayed cardioversion group had significantly higher scores for Convenience, Effectiveness, and Global satisfaction (81.74 vs. 65.78; 39.41 vs. 32.95; and 82.07 vs. 66.74, respectively; P < 0.0001). Based on the total patient population included in the treatment satisfaction substudy (n = 632) in the delayed cardioversion group in X-VeRT, the use of rivaroxaban was estimated to result in a saving of £421 and €360 per patient in UK and Italian settings, respectively. Conclusion The use of rivaroxaban in the setting of cardioversion resulted in greater patient satisfaction and cost savings, compared with that of VKA.
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Affiliation(s)
- Stefan H Hohnloser
- Department of Cardiology, Division of Clinical Electrophysiology, J.W. Goethe University, Frankfurt, Germany
| | - Riccardo Cappato
- Arrhythmia and Electrophysiology Center, IRCCS Humanitas Research Hospital, Milan, Italy Humanitas Gavazzeni Hospital, Bergamo, Italy
| | - Michael D Ezekowitz
- The Sidney Kimell Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Kurtulus Sahin
- ClinStat GmbH, Statistics and Health Economics, Cologne, Germany
| | - Paulus Kirchhof
- Centre for Cardiovascular Sciences, School of Clinical and Experimental Medicine, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham, UK Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
| | | | | | - A John Camm
- Division of Clinical Sciences, St George's, University of London, London, UK
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Andò G, Trio O, Carerj S. New oral anticoagulants versus vitamin K antagonists before cardioversion of atrial fibrillation: a meta-analysis of data from 4 randomized trials. Expert Rev Cardiovasc Ther 2015; 13:577-83. [DOI: 10.1586/14779072.2015.1024107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Dentali F, Botto GL, Gianni M, Ambrosino P, Di Minno MND. Efficacy and safety of direct oral anticoagulants in patients undergoing cardioversion for atrial fibrillation: A systematic review and meta-analysis of the literature. Int J Cardiol 2015; 185:72-7. [PMID: 25791094 DOI: 10.1016/j.ijcard.2015.03.096] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 03/07/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND DOACs are increasingly used in patients with NVAF. Information on efficacy and safety of these compounds in patients undergoing electrical or pharmacological cardioversion is limited. Thus, we performed a systematic review and a meta-analysis of the literature to address this issue. METHODS Randomized controlled trials comparing the efficacy and safety of DOACs and VKAs in patients with NVAF were systematically searched in Medline, Web of Science, Scopus, Cochrane, and EMBASE databases (up to September 2014). Pooled relative risk (RR) and the corresponding 95% confidence interval (CI) were calculated for each outcome. RESULTS Four randomized controlled trials (3635 patients), for a total of 4517 cardioversions (2869 with DOACs and 1648 with VKAs), were included in the analysis. DOACs and VKAs appeared equally effective in the prevention of stroke/systemic embolism (0.41% vs 0.61%; RR: 0.73, 95% CI: 0.31, 1.72; P=0.48) and of post-cardiovascular death (0.52% vs 0.81%; RR: 0.73, 95% CI: 0.27, 2.03; P=0.55), with a similar risk of major bleeding complications (0.81% vs 0.60%; RR: 1.23, 95% CI: 0.55, 2.71). Heterogeneity among studies was generally absent. Furthermore, the Weighted Mean Incidence (WMI) of complications appeared very low in patients randomized to DOACs (WMI: 0.6% and 0.9% for stroke/systemic embolism and major bleeding, respectively). CONCLUSION Our results suggest that DOACs are at least as effective and safe as VKAs in patients with NVAF undergoing to an electrical or pharmacological cardioversion. Thus, DOACs may be considered a valid and practical alternative to VKAs.
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Affiliation(s)
- Francesco Dentali
- Department of Clinical Medicine, Insubria University, Varese, Italy.
| | | | - Monica Gianni
- Department of Cardiology, Hospital of Tradate, Tradate, Italy
| | - Pasquale Ambrosino
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
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