Abstract

BackgroundDirect oral anticoagulants (DOACs) have emerged as the preferred choice of oral anticoagulation in patients with atrial fibrillation. Randomized trials have demonstrated the efficacy and safety of DOAC in patients undergoing electrical cardioversion (ECV); however, there is limited real-world data. ObjectiveTo evaluate the outcome of patients undergoing an elective ECV for atrial tachyarrhythmia in a tertiary referral center who were treated with DOAC or vitamin K antagonist (VKA) without routine trans esophageal echocardiography (TEE). MethodsThis was a retrospective single-center cohort study of consecutive patients undergoing an elective ECV for atrial tachyarrhythmia from January 2013 to February 2020. The primary endpoints were thromboembolism (composite of stroke, transient ischemic attack or systemic embolism) and major bleeding events within 60 days. ResultsA total of 1431 ECV procedures were performed in 920 patients. One-third of the procedures were performed under DOAC (N = 488, 34%) and the remainder of the procedures was performed under VKA (N = 943, 66%). There were no differences between groups with regard to demographic variables (mean age 62.4 ± 11.7, 72% men) and mean CHA2DS2-VASc score (2.3 ± 1.6); however, the VKA group had a higher proportion of patients with co-morbidity. Thromboembolism occurred in 0.41% in the DOAC group versus 0.64% in the VKA group (P = 0.72). Major bleeding events occurred in 0.41% in the DOAC group versus 0.11% in the VKA group (P = 0.27). ConclusionIn a real-world population, the rates of thromboembolism and major bleeding events were low after elective ECV in patients using DOAC or VKA, even without routine TEE.

Highlights

  • Direct oral anticoagulants (DOACs) are currently the preferred choice of oral anticoagulation in patients with atrial fibrillation (AF) for longterm stroke prevention [1]

  • We evaluated the efficacy and safety of DOACs versus vitamin K antagonist (VKA) in patients undergoing elective electrical cardioversion (ECV) for atrial tachyarrhythmia in a large tertiary referral center without routine preprocedural trans esophageal echocardiography (TEE)

  • In patients using VKA, the International Normalized Ratio (INR) level had to be in the therapeutic range (≥2.0) in the 3 weeks prior to the procedure

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Summary

Introduction

Direct oral anticoagulants (DOACs) are currently the preferred choice of oral anticoagulation in patients with atrial fibrillation (AF) for longterm stroke prevention [1]. Prospective randomized controlled trials (RCTs) in patients requiring elective ECV demonstrated low and similar thromboembolic and bleeding rates when comparing factor Xa inhibitors to vitamin K antagonists (VKA) [7,8,9]. Randomized trials have demonstrated the efficacy and safety of DOAC in patients undergoing electrical cardioversion (ECV); there is limited real-world data. Objective: To evaluate the outcome of patients undergoing an elective ECV for atrial tachyarrhythmia in a tertiary referral center who were treated with DOAC or vitamin K antagonist (VKA) without routine trans esophageal echocardiography (TEE). Conclusion: In a real-world population, the rates of thromboembolism and major bleeding events were low after elective ECV in patients using DOAC or VKA, even without routine TEE

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