Thromboembolic Complications After

Cardioversion of Acute Atrial Fibrillation

The FinCV (Finnish CardioVersion) Study

Dr. Rahul Shewale
23/04/16

Journal of the American College of Cardiology

AF
• Anticoagulation is recommended for 3 weeks before and 4 weeks
after cardioversion for patients with atrial fibrillation of unknown
duration or duration >48 h.
• it has been a common practice to cardiovert acute (<48 h) atrial
fibrillation without anticoagulation .
• This practice has been recently called into question, and recent
guidelines recommend anticoagulation therapy during and after
cardioversion in patients with acute atrial fibrillation and risk factors
for stroke.
• Because the new recommendations are based mainly on consensus,
and no randomized trials are available,
• this trial decided to evaluate the incidence and risk factors of
thromboembolic complications after successful cardioversion of acute
atrial fibrillation when no anticoagulation is used.
AIM
To study the incidence and risk factors of thromboembolic
complications after cardioversion of acute atrial fibrillation.
Methods
• A total of 7,660 cardioversions were performed in 3,143 consecutive
patients with atrial fibrillation lasting <48 h in 3 hospitals.
• For this analysis, embolic complications were evaluated during the 30
days after 5,116 successful cardioversions in 2,481 patients with
neither oral anticoagulation nor peri-procedural heparin therapy.
• All patients (>18 years of age) with acute (<48 h) atrial fibrillation who
underwent cardioversion during the study period were identified
from the registries in the 3 participating hospitals.
• A total of 7,237 consecutive cardioversions were identified in 3,143
patients with acute (<48 h) atrial fibrillation treated at the emergency
clinics.
• Of the 7,237 successful cardioversions, 5,116 were performed
without peri-procedural and post-cardioversion oral anticoagulation
or heparin, and these cardioversions were included in the present
analysis.
• Total number of the included patients was 2,481.
• Cardioversion was considered successful if sinus rhythm was restored
and the patient was discharged from the cardioversion unit in sinus
rhythm.
• All case records were reviewed during the index cardioversion and
during a 30-day follow-up after cardioversion.
• All possible thromboembolic and bleeding complications, death, and
any conditions that caused the patient to consult a physician within
30 days after the cardioversion were recorded
primary study outcome
• It was definite thromboembolic event within 30 days after index
cardioversion.
• Definite thromboembolic event was defined as a stroke documented
clinically and confirmed by CT / MRI to be caused by cerebral
infarction or a systemic embolism confirmed by imaging, surgery, or
autopsy.
• Probable embolic complications included TIA that were not confirmed
by imaging BUT suspected clinically, not confirmed by imaging
Results
• Cardioversion was successful in 5,116 (95.4%) of the 5,362
procedures in 2,481 patients who had no peri-procedural oral
anticoagulation or heparin therapy.
• A great majority (88%) of cardioversions were electrical.
• Thirty-eight definite embolic events occurred in 38 patients (0.7% of
successful procedures and 31 of these were strokes.
• One patient experienced both stroke and systemic embolism
• Two patients suffered from pulmonary embolism, and there were 11
deaths during the 30-day follow-up .
• There were no major bleeding complications during the follow-up,
Predictors of Definite Thromboembolism
after cardioversion for atrial fibrillation
Thromboembolic Complications After Cardioversion of Acute
Atrial Fibrillation: The FinCV (Finnish CardioVersion) Study

Figure Legend:

Incidence of TE After Cardioversion

Variation of the risk of definite thromboembolic complications (TE) after cardioversion of acute (duration <48 h) atrial fibrillation
(AF), according to the chi-square automatic interaction detection analysis.

Date of download: 4/21/2016 Copyright © The American College of Cardiology. All rights reserved.
Definite predictors
• heart failure,
• diabetes
• age >60 years
• were predictive of post-procedural definite thromboembolism.
• results show that, in general, embolic events are quite rare (<1%)
within 30 days after cardioversion of acute atrial fibrillation, even
without perioperative anticoagulation.
• increasing age, female sex, heart failure, and diabetes increase the
risk of thromboembolic complications substantially, and in the
presence of multiple risk factors, the risk becomes unacceptably high
(approximately 10%)
• Interestingly, both of the recommended stroke risk scores CHADS2,
CHADS2VASC were highly predictive for thromboembolism also in this
acute setting.
Discussion
AF
• Most embolic events occurred shortly after successful cardioversion, which
supports the view that the conversion of atrial arrhythmia to sinus rhythm
is responsible for the thromboembolism also after short attacks (<48 h) of
arrhythmia .
• It is also noteworthy that the absence of thrombus before cardioversion
does not guarantee safe cardioversion.
• because restoration of sinus rhythm results in a fall in blood flow velocity
of the left atrial appendage, and it is now generally accepted that this
accentuation of atrial stasis promotes new thrombus formation and
predisposes to embolization.
• observations in this study are in agreement with these data
• and suggest that atrial stunning might also occur in the setting of short
attacks of atrial fibrillation and render to embolic event.
• Regardless of whether cardioversion is performed pharmacologically
or electrically, therapeutic anticoagulation is necessary for 3 weeks or
longer before cardioversion to prevent thromboembolic
complications if the AF has been ongoing for more than 48 hours.
• If the time of onset of AF is unclear, for the sake of safety, the
duration of AF should be assumed to be greater than 48 hours.
• These patients should receive therapeutic anticoagulation for 4 weeks
after cardioversion to prevent the thromboembolic complications
that may occur because of atrial stunning.
• At the time of this study, European and American guidelines did not
have solid recommendations about anticoagulation in recent-onset
(<48 h) atrial fibrillation.
• Thus, a general approach was to convert atrial fibrillation without
post-cardioversion oral anticoagulants as long as there was a clear
history of arrhythmia onset within 48 h from the scheduled
cardioversion.
• This practice was called into question in 2010 when the European
guidelines recommended effective perioperative and long-term
anticoagulation in patients with risk factors for stroke.
• In patients with a definite AF onset ,48 h, cardioversion can be
performed expediently under the cover of UFH administered i.v.
followed by infusion or subcutaneous LMWH.
• In patients with risk factors for stroke, UFH or LMWH should be
continued. OAC should be started after cardioversion until the INR is
at the therapeutic level (2.0–3.0) and continued lifelong.
• No OAC is required in patients without thrombo-embolic risk factors.
CHADS2VASC – Stroke Risk Assesment
• CLASS I
• For patients with AF or atrial flutter of less than 48 hours’ duration
and with high risk of stroke, intravenous heparin or LMWH, or
administration of a factor Xa or direct thrombin inhibitor, is
recommended as soon as possible before or immediately after
cardioversion, followed by long-term anticoagulation therapy.
• (Level of Evidence: C)
• CLASS IIb
• 1. For patients with AF or atrial flutter of less than 48 hours’ duration
who are at low thromboembolic risk,
• may be considered for cardioversion, without the need for
postcardioversion longterm oral anticoagulation .
• (Level of Evidence: C)
• The implementation of the guideline has been slow, because the
evidence behind the recommendation is circumstantial and
supported only by small retrospective cardioversion studies.
Study limitations.
• A retrospective study does not allow characterization of the study
cohort as accurately as in a well-executed prospective trial.
• An important limitation was that the onset of atrial fibrillation was
based on onset of symptoms. It is well-known that symptoms might
not be reliable for accurate marking of onset of atrial fibrillation.
Conclusions
• in this large multicenter, retrospective patient cohort show that,
although in general the risk of definite thromboembolic events after
cardioversion of acute atrial fibrillation is quite low, it becomes
unacceptably high in patients with conventional risk factors for
thromboembolism.
• This study support the current recommendation that these patients
need effective peri-procedural anticoagulation followed by long-
term oral anticoagulation
THANK YOU