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Role of prophylactic anticoagulation for direct current cardioversion in patients with atrial fibrillation or atrial
A Z Arnold1, M J Mick, R P Mazurek
1Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195.
Insights
Prophylactic anticoagulation is crucial before cardioversion for atrial fibrillation, even for short durations. Anticoagulation is not recommended for atrial flutter cardioversion, as no embolic events occurred in these patients.
Area of Science:
- Cardiology
- Neurology
- Vascular Medicine
Background:
- The necessity of prophylactic anticoagulation before direct current cardioversion for atrial fibrillation or atrial flutter remains debated.
- Embolic complications pose a significant risk following cardioversion procedures.
Purpose of the Study:
- To retrospectively evaluate the incidence of embolic complications after direct current cardioversion.
- To determine the role of prophylactic anticoagulation in preventing these complications.
Main Methods:
- Retrospective review of 454 elective direct current cardioversions over a 7-year period.
- Analysis of patient characteristics and outcomes, comparing those with and without embolic events.
Main Results:
- An overall embolic complication rate of 1.32% (6 patients) was observed.
- All embolic events occurred in patients with atrial fibrillation, none of whom received anticoagulation (p = 0.026).
- Five of six patients with embolic complications had atrial fibrillation for less than one week; no embolic events occurred in patients with atrial flutter.
Conclusions:
- Prophylactic anticoagulation is essential for patients undergoing cardioversion for atrial fibrillation, irrespective of symptom duration.
- Anticoagulation is not recommended for patients with atrial flutter undergoing cardioversion due to the absence of embolic complications in this group.
Abstract:
The need for prophylactic anticoagulation to prevent embolism before direct current cardioversion is performed for atrial fibrillation or atrial flutter is controversial. To examine this issue further, a retrospective review was undertaken to assess the incidence of embolic complications after cardioversion. The review involved 454 elective direct current cardioversions performed for atrial fibrillation or atrial flutter over a 7 year period. The incidence rate of embolic complications was 1.32% (six patients); the complications ranged from minor visual disturbances to a fatal cerebrovascular event. All six patients had atrial fibrillation, and none had been on anticoagulant therapy (p = 0.026). The duration of atrial fibrillation was less than 1 week in five of the six patients who had embolic complications. Baseline characteristics of patients with a postcardioversion embolic event are compared with those of patients who did not have an embolic event. There was no difference in the prevalence of hypertension, diabetes mellitus or prior stroke between the two groups, and there was no difference in the number of patients who were postoperative or had poor left ventricular function. Left atrial size was similar between the two groups. No patient in the embolic group had valvular disease. No patient with atrial flutter had an embolic event regardless of anticoagulant status; therefore, anticoagulation is not recommended for patients with atrial flutter undergoing cardioversion. Prophylactic anticoagulation is pivotal in patients undergoing elective direct current cardioversion for atrial fibrillation, even those with atrial fibrillation of less than 1 week's duration.