Target-specific oral anticoagulants in patients undergoing cardioversion

Published evidence on the use of target-specific oral anticoagulants (TSOAs) versus traditional warfarin therapy in patients undergoing cardioversion for atrial fibrillation (AF) is reviewed.

A literature search for published studies evaluating the TSOAs apixaban, dabigatran, and rivaroxaban as alternatives to warfarin for the prevention of thromboembolic events before and after cardioversion for AF identified a limited number of pertinent articles. Three of the four identified articles presented the results of retrospective analyses of data on TSOA use in relatively small cohorts of patients with AF who underwent cardioversion procedures during large clinical trials (RE-LY, ROCKET AF, and ARISTOTLE) that were not specifically designed to assess outcomes with TSOA use versus warfarin use. Those post hoc analyses did not indicate significant differences between groups of TSOA- and warfarin-treated patients in any of the clinical outcomes evaluated, including rates of stroke, systemic embolism, acute myocardial infarction, bleeding events, and 30-day and longer-term mortality. Anticipated reports on two trials of rivaroxaban (one recently completed and another scheduled for completion in 2014) are expected to provide additional insights on optimal strategies for anticoagulant prophylaxis in the context of AF cardioversion.

A limited body of published evidence suggests that dabigatran and apixaban may be effective alternatives to warfarin for anticoagulation therapy in patients with AF undergoing cardioversion. Careful consideration of the risks and benefits of TSOA versus warfarin use and patient preferences are key factors in appropriate drug selection.