Transesophageal echocardiography-guided cardioversion resulted in similar rates of embolic events compared to conventional treatment (0.8% vs 0.5%, P=0.50) but significantly fewer hemorrhagic events.
RCT (n=1,222)
randomized
Yes
Does transesophageal echocardiography-guided treatment reduce embolic events compared to conventional treatment in patients with atrial fibrillation of more than two days' duration?
Transesophageal echocardiography-guided cardioversion is a clinically effective alternative to conventional 3-week anticoagulation, offering similar protection against embolic events with fewer bleeding complications and a shorter time to cardioversion.
Absolute Event Rate: 0.8% vs 0.5%
p-value: p=0.50
BACKGROUND: The conventional treatment strategy for patients with atrial fibrillation who are to undergo electrical cardioversion is to prescribe warfarin for anticoagulation for three weeks before cardioversion. It has been proposed that if transesophageal echocardiography reveals no atrial thrombus, cardioversion may be performed safely after only a short period of anticoagulant therapy. METHODS: In a multicenter, randomized, prospective clinical trial, we enrolled 1222 patients with atrial fibrillation of more than two days' duration and assigned them to either treatment guided by the findings on transesophageal echocardiography or conventional treatment. The composite primary end point was cerebrovascular accident, transient ischemic attack, and peripheral embolism within eight weeks. Secondary end points were functional status, successful restoration and maintenance of sinus rhythm, hemorrhage, and death. RESULTS: There was no significant difference between the two treatment groups in the rate of embolic events (five embolic events among 619 patients in the transesophageal-echocardiography group 0.8 percent) vs. three among 603 patients in the conventional-treatment group 0.5 percent, P=0.50). However, the rate of hemorrhagic events was significantly lower in the transesophageal-echocardiography group (18 events 2.9 percent vs. 33 events 5.5 percent, P=0.03). Patients in the transesophageal-echocardiography group also had a shorter time to cardioversion (mean +/-SD, 3.0+/-5.6 vs. 30.6+/-10.6 days, P<0.001) and a greater rate of successful restoration of sinus rhythm (440 patients 71.1 percent vs. 393 patients 65.2 percent, P=0.03). At eight weeks, there were no significant differences between the two groups in the rates of death or maintenance of sinus rhythm or in functional status. CONCLUSIONS: The use of transesophageal echocardiography to guide the management of atrial fibrillation may be considered a clinically effective alternative strategy to conventional therapy for patients in whom elective cardioversion is planned.
Klein et al. (2001) conducted an RCT in Atrial fibrillation (n=1,222). Transesophageal echocardiography-guided treatment vs. Conventional treatment (warfarin for three weeks before cardioversion) was evaluated on Composite of cerebrovascular accident, transient ischemic attack, and peripheral embolism within eight weeks (p=0.50). Transesophageal echocardiography-guided cardioversion resulted in similar rates of embolic events compared to conventional treatment (0.8% vs 0.5%, P=0.50) but significantly fewer hemorrhagic events.