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Factors determining elective cardioversion preceded by transesophageal echocardiography: experiences of 2 cardiology
Beata Uziębło-Życzkowska1, Marek Kiliszek1, Iwona Gorczyca2
1Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
Insights
Despite guidelines, most atrial fibrillation patients still get transesophageal echocardiography (TEE) before cardioversion. History of CAD, bleeding, or stroke increases TEE likelihood, while paroxysmal AF and hypertension decrease it.
Area of Science:
- Cardiology
- Electrophysiology
Background:
- Current guidelines recommend cardioversion for atrial fibrillation (AF) patients after adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without requiring transesophageal echocardiography (TEE).
- However, a significant majority of patients still undergo TEE prior to cardioversion, indicating a discrepancy between guidelines and clinical practice.
Purpose of the Study:
- To identify the key factors influencing the decision to perform TEE in patients with atrial fibrillation (AF) who are candidates for elective cardioversion.
- To understand the clinical predictors associated with TEE utilization in this patient population.
Main Methods:
- Retrospective evaluation of medical records from consecutive AF patients undergoing elective cardioversion after NOAC treatment.
- Statistical analysis, including univariable and multivariable logistic regression, was employed to identify predictors of TEE performance.
Main Results:
- Of 668 patients, 54% underwent TEE. Independent predictors for TEE included a history of coronary artery disease (CAD), bleeding, and stroke/transient ischemic attack/thromboembolism.
- Conversely, paroxysmal AF and hypertension were independently associated with refraining from TEE.
Conclusions:
- Transesophageal echocardiography is frequently performed before cardioversion, particularly in patients with a history of CAD, bleeding, or thromboembolic events.
- Patients with paroxysmal AF and hypertension are more likely to undergo cardioversion without pre-procedural TEE, suggesting these factors influence clinical decision-making.
Introduction:
Although guidelines endorse cardioversion after adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without prior transesophageal echocardiography (TEE), the majority of patients still undergo this examination.
Objectives:
The aim of this study was to assess factors determining the decision to perform TEE in patients with atrial fibrillation (AF) who are eligible for elective cardioversion.
Patients And Methods:
In this study, we evaluated the medical records of consecutive patients with AF who were admitted for elective cardioversion after prior NOAC treatment.
Results:
Of a total of 668 patients included in the study, 362 individuals (54%) underwent TEE before cardioversion. In the univariable analysis, paroxysmal AF, hypertension, coronary artery disease (CAD), thromboembolic events, a history of percutaneous coronary intervention, a history of bleeding, left ventricular ejection fraction, left ventricular end‑ diastolic diameter, a reduced dose of NOACs, hemoglobin levels, impaired renal filtration, and a high CHA2DS2‑VASc score were significant predictors of the decision to perform TEE. In the multivariable logistic regression analysis, a history of CAD, bleeding, and stroke / transient ischemic attack / thromboembolism remained independent predictors of referring a patient for TEE (odds ratio [OR], 3.92, P <0.001; OR, 7.92, P <0.001; and OR, 2.36, P = 0.02, respectively). In contrast, paroxysmal AF (OR, 0.31; P = 0.02) and hypertension (OR, 0.28; P <0.001) were indicators of refraining from TEE.
Conclusions:
Transesophageal echocardiography before cardioversion was more frequently performed in patients with a history of CAD, bleeding, or thromboembolic events. Patients with paroxysmal AF and hypertension more often received cardioversion without prior TEE.
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