Are Three Weeks of Oral Anticoagulation Sufficient for Safe Cardioversion in Atrial Fibrillation?

Q: What are the key findings of this study?

Three weeks of DOAC treatment reduced spontaneous echo contrast (50.9% to 25.0%) and left atrial thrombosis (19.6% to 14.5%), but the high residual incidence suggests 3 weeks may be insufficient for safe cardioversion in all patients.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial Fibrillation (n=51). Intervention: Direct oral anticoagulants (DOACs) vs. Baseline status (pre-treatment). Primary outcome: Prevalence of spontaneous echo contrast (SEC) (p=<0.05).

Q: What does this research mean for the field?

Three weeks of DOAC treatment reduces the prevalence of left atrial thrombosis from 19.6% to 14.5% and spontaneous echo contrast from 50.9% to 25.0% in atrial fibrillation patients, though the persistence of these conditions suggests a need for individualized anticoagulation duration before cardioversion. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

Stefan Naydenov; Nikolay Runev; Емил Manov

doi:10.3390/medicina57060554

May 31, 2021MedicinaOpen Access

Are Three Weeks of Oral Anticoagulation Sufficient for Safe Cardioversion in Atrial Fibrillation?

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Key result

Three weeks of DOACs cuts spontaneous echo contrast by ~26 percentage points before cardioversion.

P<0.05
n=51

Figures

Why the study?

The optimal duration of anticoagulation in the presence of overt left atrial thrombosis prior to cardioversion in atrial fibrillation is unknown.

Does 3 weeks of DOAC treatment adequately reduce spontaneous echo contrast and left atrial thrombosis in patients with atrial fibrillation planned for cardioversion?

Study Design

Type

Cohort (n=51)

Blinding

Open-label

Structured PICO

Does 3 weeks of DOAC treatment adequately reduce spontaneous echo contrast and left atrial thrombosis in patients with atrial fibrillation planned for cardioversion?

P

Population

51 symptomatic patients (mean age 69.3, 49.1% female) with paroxysmal or unknown-duration atrial fibrillation planned for cardioversion underwent TEE before and 3 weeks after starting DOAC treatment.

I

Intervention

Direct oral anticoagulants (DOACs), predominantly dabigatran, administered for 3 weeks prior to planned cardioversion.

C

Comparator

Baseline evaluation before DOAC initiation (within-subject comparison).

O

Outcome

Prevalence of spontaneous echo contrast (SEC) and left atrial thrombosis (LAT) at 3 weeks via transesophageal echocardiography.surrogate

Main Result

Absolute Event Rate: 25% vs 50.9%

p-value: p=<0.05

A standard 3-week DOAC regimen prior to cardioversion leaves a substantial proportion of AF patients with residual spontaneous echo contrast or left atrial thrombus, suggesting that imaging guidance may be necessary for high-risk left atrial morphologies.

Limitations

Small sample size, especially of patients with left atrial thrombosis
Most patients were treated with dabigatran, limiting generalizability to other DOACs
Short follow-up period of 3 weeks
Investigated some, but not all, factors that might be related to the persistence of SEC/LAT
Small sample size
Most patients received dabigatran, limiting findings for other DOACs
Short 3-week follow-up period
Not all potential predictors for SEC/LAT persistence were analyzed

Implication

Residual SEC/LAT after 3-week DOAC may warrant pre-cardioversion imaging in high-risk AF; leaves open optimal duration or selection.

Abstract

Background and Objectives: Patients with atrial fibrillation (AF), lasting >48 h, considered for cardioversion, are recommended ≥3 weeks of oral anticoagulation before sinus rhythm restoration because of high risk of development of left atrial thrombosis (LAT) and stroke. However, the optimal duration of anticoagulation in the presence of overt LAT is unknown. Materials and Methods: An open-label study aimed to investigate the prevalence of spontaneous echo contrast (SEC) and LAT before and after 3 weeks of direct oral anticoagulant (DOAC) treatment. We included 51 consecutive patients (50.9% males), mean age 69.3 ± 7.4 years with paroxysmal/unknown duration of AF, considered for cardioversion, who agreed to have transesophageal echocardiography at enrollment and 3 weeks later. Results: At baseline SEC was present in 26 (50.9%) and LAT in 10 (19.6%) of 51 patients. After 3 weeks on DOAC, SEC persisted in 12 (25.0%) and LAT in 7 (14.5%) of 48 patients, p < 0.05 vs. baseline. Factors, associated most strongly with persistence of SEC/LAT, were left atrial appendage (LAA) emptying velocity <20 cm/s (OR = 2.82), LAA lobes >2 (OR = 1.84), and indexed left atrial volume ≥34 mL/m2 (OR = 1.37). Conclusions: In our study the incidence of SEC/LAT, particularly in AF with unknown duration, was not as low as we expected. The prevalence of SEC/LAT seemed to be dependent on factors not routinely evaluated in AF patients planned for cardioversion (indexed LA volume, LAA morphology and number of lobules, LAA emptying velocity, etc.). Our data suggested an individualized approach for DOAC duration in AF patients before an attempt for restoration of sinus rhythm is made, taking into consideration the LAA morphology and function.

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Cite This Study

Naydenov et al. (2021) conducted a cohort in Atrial Fibrillation (n=51). Direct oral anticoagulants (DOACs) vs. Baseline status (pre-treatment) was evaluated on Prevalence of spontaneous echo contrast (SEC) (p=<0.05). Three weeks of DOAC treatment reduced spontaneous echo contrast (50.9% to 25.0%) and left atrial thrombosis (19.6% to 14.5%), but the high residual incidence suggests 3 weeks may be insufficient for safe cardioversion in all patients.

synapsesocial.com/papers/6a23992e8ac8ec529b08ebcc https://doi.org/10.3390/medicina57060554