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Itäinen-Strömberg S, Lehto M, Halminen O, Putaala J, Haukka J, Lehtonen O, Teppo K, Mustonen P, Linna M, Hartikainen J, Airaksinen KEJ, Aro AL. Thromboembolic and bleeding complications after elective cardioversion of atrial fibrillation: a nationwide cohort study. Europace 2024; 26:euae131. [PMID: 38829189 PMCID: PMC11146156 DOI: 10.1093/europace/euae131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 05/09/2024] [Indexed: 06/05/2024] Open
Abstract
AIMS Elective cardioversion (ECV) is routinely used in atrial fibrillation (AF) to restore sinus rhythm. However, it includes a risk of thromboembolism even during adequate oral anticoagulation treatment. The aim of this study was to evaluate the risk of thromboembolic and bleeding complications after ECV in a real-life setting utilizing data from a large AF population. METHODS AND RESULTS This nationwide register-based study included all (n = 9625) Finnish AF patients undergoing their first-ever ECV between 2012 and 2018. The thromboembolic and bleeding complications within 30 days after ECV were analysed. The mean age of the patients was 67.7 ± 9.9 years, 61.2% were men, and the mean CHA2DS2-VASc score was 2.6 ± 1.6. Warfarin was used in 6245 (64.9%) and non-vitamin K oral anticoagulants (NOACs) in 3380 (35.1%) cardioversions. Fifty-two (0.5%) thromboembolic complications occurred, of which 62% were ischaemic strokes, 25% transient ischaemic attacks, and 13% other systemic embolisms. Thromboembolic events occurred in 14 (0.4%) NOAC-treated patients and in 38 (0.6%) warfarin-treated patients (odds ratio 0.77; confidence interval: 0.42-1.39). The median time from ECV to the thromboembolic event was 2 days, and 78% of the events occurred within 10 days. Age and alcohol abuse were significant predictors of thromboembolic events. Among warfarin users, thromboembolic complications were more common with international normalized ratio (INR) <2.5 than INR ≥2.5 (0.9% vs. 0.4%, P = 0.026). Overall, 27 (0.3%) bleeding events occurred. CONCLUSION The rate of thromboembolic and bleeding complications related to ECV was low without significant difference between NOAC- and warfarin-treated patients. With warfarin, INR ≥2.5 at the time of cardioversion reduced the risk of thromboembolic complications.
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Affiliation(s)
- Saga Itäinen-Strömberg
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland
| | - Mika Lehto
- Jorvi Hospital, Department of Internal Medicine, HUS Helsinki University Hospital, Espoo, Finland
- University of Helsinki, Faculty of Medicine, Helsinki, Finland
| | - Olli Halminen
- Aalto University, Department of Industrial Engineering and Management, Espoo, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Clinicum, Finland
| | - Ossi Lehtonen
- University of Eastern Finland, School of Medicine, Kuopio, Finland
| | - Konsta Teppo
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Pirjo Mustonen
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Miika Linna
- Aalto University, Department of Industrial Engineering and Management, Espoo, Finland
- University of Eastern Finland, School of Medicine, Kuopio, Finland
| | - Juha Hartikainen
- University of Eastern Finland, School of Medicine, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Aapo L Aro
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland
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Jain P, Patel V, Patel Y, Rasool J, Gandhi SK, Patel P. Effectiveness of Transesophageal Echocardiography in Preventing Thromboembolic Complications Before Cardioversion: A Narrative Review. Cureus 2023; 15:e48149. [PMID: 38046740 PMCID: PMC10692994 DOI: 10.7759/cureus.48149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 12/05/2023] Open
Abstract
Atrial fibrillation (AFib) is one of the most prevalent irregular heartbeats that doctors encounter. Clinicians typically pursue two main approaches for treatment, namely, controlling the heart rate and managing the heart rhythm. Under the rhythm control approach, AFib is addressed through cardioversion, which is achieved either with medications termed pharmacological cardioversion (PCV) or via an electrical shock termed electric cardioversion (ECV). While ECV proves instrumental in AFib management, it carries its own risk factors, potentially leading to blood clot-related complications such as embolic strokes. To counteract this potential downside, a well-established strategy involves the utilization of transesophageal echocardiography (TEE) to identify possible embolic sources before initiating cardioversion. The goal of this systematic review is to highlight the role of TEE in preempting embolic occurrences following ECV during the management of AFib. After conducting a thorough search of databases, namely, PubMed, PubMed Central, and Medline, a total of 36 studies were selected for this review article. Following a comprehensive evaluation of these studies, it was concluded that TEE plays a pivotal role in preventing thromboembolic complications during ECV for AFib. However, it is important to note that further research is needed to delve deeper into this matter. While existing evidence underscores its efficacy, additional investigation is needed to address this subject matter comprehensively.
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Affiliation(s)
- Prateek Jain
- Department of Internal Medicine, Maulana Azad Medical College, Delhi, IND
| | - Vishwesh Patel
- Department of Internal Medicine, M.P. Shah Government Medical College, Jamnagar, IND
| | - Yashaswi Patel
- Department of Internal Medicine, Government Medical College, Surat, Surat, IND
| | - Jawairiya Rasool
- Department of Internal Medicine, Dow International Medical College, Karachi, PAK
| | | | - Priyansh Patel
- Department of Internal Medicine, Medical College Baroda, Vadodara, IND
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How to Optimize Cardioversion of Atrial Fibrillation. J Clin Med 2022; 11:jcm11123372. [PMID: 35743443 PMCID: PMC9225082 DOI: 10.3390/jcm11123372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/22/2022] [Accepted: 06/10/2022] [Indexed: 12/07/2022] Open
Abstract
Cardioversion (CV) is an essential component of rhythm control strategy in the treatment of atrial fibrillation (AF). Timing of CV is an important manageable factor in optimizing the safety and efficacy of CV. Based on observational studies, the success rate of CV seems to be best (≈95%) at 12−48 h after the onset of arrhythmic symptoms compared with a lower success rate of ≈85% in later elective CV. Early AF recurrences are also less common after acute CV compared with later elective CV. CV causes a temporary increase in the risk of thromboembolic complications. Effective anticoagulation reduces this risk, especially during the first 2 weeks after successful CV. However, even during therapeutic anticoagulation, each elective CV increases the risk of stroke 4-fold (0.4% vs. 0.1%) during the first month after the procedure, compared with acute (<48 h) CV or avoiding CV. Spontaneous CVs are common during the early hours of AF. The short wait-and-see approach, up to 24−48 h, is a reasonable option for otherwise healthy but mildly symptomatic patients who are using therapeutic anticoagulation, since they are most likely to have spontaneous rhythm conversion and have no need for active CV. The probability of early treatment failure and antiarrhythmic treatment options should be evaluated before proceeding to CV to avoid the risks of futile CVs.
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Prevalence and Rate of Resolution of Left Atrial Thrombus in Patients with Non-Valvular Atrial Fibrillation: A Two-Center Retrospective Real-World Study. J Clin Med 2022; 11:jcm11061520. [PMID: 35329845 PMCID: PMC8948620 DOI: 10.3390/jcm11061520] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/27/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022] Open
Abstract
Background and aim. Thromboembolic events due to left atrial appendage (LAA) thrombosis are the main complication of non-valvular atrial fibrillation (NVAF). Although anticoagulants are effective in patients with NVAF, a minimal residual thromboembolic risk persists. Little is known about the prevalence of LAA thrombus and the rate of resolution after the recommended period of anticoagulation therapy, including vitamin K antagonists (VKA), heparin, and non-vitamin K antagonist oral anticoagulants (NOACs). Methods and results. We aimed to study the prevalence of LAA thrombus in an unselected cohort of patients undergoing transesophageal echocardiogram (TEE), and the determinants of LAA thrombus resolution. We retrospectively analyzed 8888 consecutive TEEs performed over five years in two high-volume centers and included all patients with LAA thrombus. A total of 265 patients (3%) had an LAA thrombus. Among these, 97% presented with AF. Fifty-eight percent of patients were on anticoagulants at least three weeks before the diagnosis. After the LAA thrombus diagnosis, VKAs were prescribed in 52%, heparin in 18.5%, and NOAC in 27% of patients. Among the 183 patients with repeat TEE, performed at (25–75th) 39 days (21–84), 67% showed resolution of the LAA thrombus. Although the rate of thrombus resolution was higher in patients treated with NOACs (NOACs 71%, VKA 66%, Heparin 60%) the difference between anticoagulants was statistically non-significant (VKA, OR 0.9, p = 0.83; NOAC, OR 1.23, p = 0.42; heparin, OR 0.69, p = 0.35). Thus, NOACs were demonstrated to be at least as effective as other anticoagulants in the rate of LAA thrombus resolution. Upon multivariate-adjusted analysis, higher LAA emptying velocities were the only predictor of thrombus resolution. In conclusion, the majority of patients were already on anticoagulants. NOACs could be at least as effective as other anticoagulants, yielding an LAA thrombus resolution in two-thirds of patients. This may have clinical relevance, especially in patients undergoing cardioversion or catheter ablation.
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Relander A, Hellman T, Vasankari T, Nuotio I, Airaksinen JKE, Kiviniemi T. Advanced interatrial block predicts ineffective cardioversion of atrial fibrillation: a FinCV2 cohort study. Ann Med 2021; 53:722-729. [PMID: 34018453 PMCID: PMC8158202 DOI: 10.1080/07853890.2021.1930139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/09/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS Rhythm control using electrical cardioversion (CV) is a common treatment strategy for patients with symptomatic atrial fibrillation (AF). To guide clinical decision making, we sought to assess if electrocardiographic interatrial blocks could predict CV failure or AF recurrence as the phenomenon is strongly associated with atrial arrhythmias. METHODS This study included 715 patients who underwent a CV for persistent AF lasting >48 h. P-wave duration and morphology were analyzed in post-procedure or the most recent sinus rhythm electrocardiograms and compared with rates of CV failure and AF recurrence within 30 days after CV as well as their combination (ineffective CV). RESULTS CV was unsuccessful in 63 out of 715 patients (8.8%) and AF recurred in 209 out of 652 (29.2%) patients within 30 days after CV. Overall, 272 (38.0%) CVs turned out ineffective. Advanced interatrial block (AIAB) defined as P-wave duration ≥120 ms and biphasic morphology in inferior leads (II, III and aVF) was diagnosed in 72 (10.1%) cases. AIAB was an independent predictor for CV failure (OR 4.51, 95%CI 1.76-11.56, p = .002), AF recurrence (OR 2.93, 95%CI 1.43-5.99, p = .003) and ineffective CV (OR 3.87, 95%CI 2.04-7.36, p < .001). CONCLUSION AIAB predicted CV failure, AF recurrence as well as their composite. This study presents an easy electrocardiographic tool for the identification of patients with persistent AF who might not benefit from an elective CV in the future.KEY MESSAGESInteratrial blocks are very common in patients with atrial fibrillation.Advanced interatrial block predicts ineffective cardioversion.
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Affiliation(s)
- Arto Relander
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Tapio Hellman
- Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Tuija Vasankari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ilpo Nuotio
- Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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Jaakkola S, Nuotio I, Hartikainen JEK, Airaksinen KEJ. Early Cardioversion for Acute Atrial Fibrillation in Low Stroke Risk Patients Is Safe Without Anticoagulation. J Am Coll Cardiol 2020; 76:226-227. [PMID: 32646574 DOI: 10.1016/j.jacc.2020.04.076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 11/15/2022]
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Shaban A, Leira EC. Neurological Complications of Cardiological Interventions. Curr Neurol Neurosci Rep 2019; 19:6. [DOI: 10.1007/s11910-019-0923-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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