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Prevalence of Intracardiac Thrombi Under Phenprocoumon, Direct Oral Anticoagulants (Dabigatran and Rivaroxaban), and Bridging Therapy in Patients With Atrial Fibrillation and Flutter

Published:December 17, 2014DOI:https://doi.org/10.1016/j.amjcard.2014.12.016
      Direct oral anticoagulants (DOACs) are effective for stroke prevention in nonvalvular atrial fibrillation (AF). Cardioversion (CV) is frequently performed in patients with AF or flutter. To further explore the safety profile of DOACs in the context of CV, we sought to assess the prevalence of intracardiac thrombi under DOAC therapy in comparison with treatment with vitamin K antagonists. A total of 672 transesophageal echocardiograms performed in 643 patients with a history of nonvalvular AF were analyzed. The median CHA2DS2-VASc score was 4. Cases were stratified according to anticoagulation with dabigatran (n = 79), rivaroxaban (n = 122), phenprocoumon (n = 180), or bridging therapy (n = 287). In a subgroup analysis, only patients receiving phenprocoumon with an international normalized ratio ≥2 on the day of the investigation or on DOAC therapy for ≥3 weeks were considered. The prevalence of intracardiac thrombi under phenprocoumon was significantly higher than under DOACs (phenprocoumon, 17.8%; all DOACs, 3.9%; dabigatran, 3.8%; rivaroxaban, 4.1%) and showed no significant difference to bridging therapy (12.5%). In patients with sufficient short-term anticoagulation, similar differences between DOAC and phenprocoumon groups were observed (phenprocoumon, 18.4%; all DOACs, 3.8%; dabigatran, 0%; rivaroxaban, 6.6%). The influence of anticoagulation medication on thrombus rates was confirmed after adjusting for baseline intergroup differences regarding left atrial size and CHA2DS2-VASc score. In conclusion, the prevalence of intracardiac thrombi was lower under DOAC therapy than under phenprocoumon in this high-risk patient cohort. Safety of CV during DOAC treatment requires further prospective evaluation.
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      References

        • Airaksinen K.E.
        • Gronberg T.
        • Nuotio I.
        • Nikkinen M.
        • Ylitalo A.
        • Biancari F.
        • Hartikainen J.E.
        Thromboembolic complications after cardioversion of acute atrial fibrillation: the FinCV (Finnish CardioVersion) study.
        J Am Coll Cardiol. 2009; 62: 1187-1192
        • Arnold A.Z.
        • Mick M.J.
        • Mazurek R.P.
        • Loop F.D.
        • Trohman R.G.
        Role of prophylactic anticoagulation for direct current cardioversion in patients with atrial fibrillation or atrial flutter.
        J Am Coll Cardiol. 1992; 19: 851-855
        • Lown B.
        • Perlroth M.G.
        • Kaidbey S.
        • Abe T.
        • Harken D.E.
        “Cardioversion” of atrial fibrillation. A report on the treatment of 65 episodes in 50 patients.
        N Engl J Med. 1963; 269: 325-331
        • Asher C.R.
        • Klein A.L.
        • The ACUTE trial
        Transesophageal echocardiography to guide electrical cardioversion in atrial fibrillation. Assessment of Cardioversion Using Transesophageal Echocardiography.
        Cleve Clin J Med. 2002; 69: 713-718
        • Grimm R.A.
        • Stewart W.J.
        • Arheart K.
        • Thomas J.D.
        • Klein A.L.
        Left atrial appendage “stunning” after electrical cardioversion of atrial flutter: an attenuated response compared with atrial fibrillation as the mechanism for lower susceptibility to thromboembolic events.
        J Am Coll Cardiol. 1997; 29: 582-589
        • Nagarakanti R.
        • Ezekowitz M.D.
        • Oldgren J.
        • Yang S.
        • Chernick M.
        • Aikens T.H.
        • Flaker G.
        • Brugada J.
        • Kamensky G.
        • Parekh A.
        • Reilly P.A.
        • Yusuf S.
        • Connolly S.J.
        Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion.
        Circulation. 2011; 123: 131-136
        • Camm A.J.
        • Kirchhof P.
        • Lip G.Y.
        • Schotten U.
        • Savelieva I.
        • Ernst S.
        • Van Gelder I.C.
        • Al-Attar N.
        • Hindricks G.
        • Prendergast B.
        • Heidbuchel H.
        • Alfieri O.
        • Angelini A.
        • Atar D.
        • Colonna P.
        • De Caterina R.
        • De Sutter J.
        • Goette A.
        • Gorenek B.
        • Heldal M.
        • Hohloser S.H.
        • Kolh P.
        • Le Heuzey J.Y.
        • Ponikowski P.
        • Rutten F.H.
        • European Heart Rhythm Association
        • European Association for Cardio-Thoracic Surgery
        • ESC Committee for Practice Guidelines
        Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).
        Europace. 2010; 12: 1360-1420
        • Camm A.J.
        • Lip G.Y.
        • De Caterina R.
        • Savelieva I.
        • Atar D.
        • Hohnloser S.H.
        • Hindricks G.
        • Kirchhof P.
        • ESC Committee for Practice Guidelines-CPG
        2012 Focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation—developed with the special contribution of the European Heart Rhythm Association.
        Europace. 2012; 14: 1385-1413
        • Patel M.R.
        • Mahaffey K.W.
        • Garg J.
        • Pan G.
        • Singer D.E.
        • Hacke W.
        • Breithardt G.
        • Halperin J.L.
        • Hankey G.J.
        • Piccini J.P.
        • Becker R.C.
        • Nessel C.C.
        • Paolini J.F.
        • Berkowitz S.D.
        • Fox K.A.
        • Califf R.M.
        • ROCKET AF Investigators
        Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.
        N Engl J Med. 2011; 365: 883-891
        • Granger C.B.
        • Alexander J.H.
        • McMurray J.J.
        • Lopes R.D.
        • Hylek E.M.
        • Hanna M.
        • Al-Khalidi H.R.
        • Ansell J.
        • Atar D.
        • Avezum A.
        • Bahit M.C.
        • Diaz R.
        • Easton J.D.
        • Ezekowitz J.A.
        • Flaker G.
        • Garcia D.
        • Geraldes M.
        • Gersh B.J.
        • Golitsyn S.
        • Goto S.
        • Hermosillo A.G.
        • Hohnloser S.H.
        • Horowitz J.
        • Mohan P.
        • Jansky P.
        • Lewis B.S.
        • Lopez-Sendon J.L.
        • Pais P.
        • Parkhomenko A.
        • Verheugt F.W.
        • Zhu J.
        • Wallentin L.
        • ARISTOTLE Committees and Investigators
        Apixaban versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2011; 365: 981-992
        • Connolly S.J.
        • Ezekowitz M.D.
        • Yusuf S.
        • Eikelboom J.
        • Oldgren J.
        • Parekh A.
        • Pogue J.
        • Reilly P.A.
        • Themeles E.
        • Varrone J.
        • Wang S.
        • Alings M.
        • Xavier D.
        • Zhu J.
        • Diaz R.
        • Lewis B.S.
        • Darius H.
        • Diener H.C.
        • Joyner C.D.
        • Wallentin L.
        • RE-LY Steering Committee and Investigators
        Dabigatran versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2009; 361: 1139-1151
        • Giugliano R.P.
        • Ruff C.T.
        • Braunwald E.
        • Murphy S.A.
        • Wiviott S.D.
        • Halperin J.L.
        • Waldo A.L.
        • Ezekowitz M.D.
        • Weitz J.I.
        • Špinar J.
        • Ruzyllo W.
        • Ruda M.
        • Koretsune Y.
        • Betcher J.
        • Shi M.
        • Grip L.T.
        • Patel S.P.
        • Patel I.
        • Hanyok J.J.
        • Mercuri M.
        • Antman E.M.
        • ENGAGE AF-TIMI 48 Investigators
        Edoxaban versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2013; 369: 2093-2104
        • Lydersen S.
        • Fagerland M.W.
        • Laake P.
        Recommended tests for association in 2 x 2 tables.
        Stat Med. 2009; 28: 1159-1175
        • Mehta C.R.
        • Patel N.R.
        Exact logistic regression: theory and examples.
        Stat Med. 1995; 14: 2143-2160
        • Yarmohammadi H.
        • Varr B.C.
        • Puwanant S.
        • Lieber E.
        • Williams S.J.
        • Klostermann T.
        • Jasper S.E.
        • Whitman C.
        • Klein A.L.
        Role of CHADS2 score in evaluation of thromboembolic risk and mortality in patients with atrial fibrillation undergoing direct current cardioversion (from the ACUTE Trial Substudy).
        Am J Cardiol. 2012; 110: 222-226
        • Flaker G.
        • Lopes R.D.
        • Al-Khatib S.M.
        • Hermosillo A.G.
        • Hohnloser S.H.
        • Tinga B.
        • Zhu J.
        • Mohan P.
        • Garcia D.
        • Bartunek J.
        • Vinereanu D.
        • Husted S.
        • Harjola V.P.
        • Rosenqvist M.
        • Alexander J.H.
        • Granger C.B.
        • ARISTOTLE Committees and Investigators
        Efficacy and safety of apixaban in patients after cardioversion for atrial fibrillation: insights from the ARISTOTLE Trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation).
        J Am Coll Cardiol. 2014; 63: 1082-1087
        • Piccini J.P.
        • Stevens S.R.
        • Lokhnygina Y.
        • Patel M.R.
        • Halperin J.L.
        • Singer D.E.
        • Hankey G.J.
        • Hacke W.
        • Becker R.C.
        • Nessel C.C.
        • Mahaffey K.W.
        • Fox K.A.
        • Califf R.M.
        • Breithardt G.
        • ROCKET AF Steering Committee & Investigators
        Outcomes after cardioversion and atrial fibrillation ablation in patients treated with rivaroxaban and warfarin in the ROCKET AF trial.
        J Am Coll Cardiol. 2013; 61: 1998-2006
        • Yadlapati A.
        • Groh C.
        • Passman R.
        Safety of short-term use of dabigatran or rivaroxaban for direct-current cardioversion in patients with atrial fibrillation and atrial flutter.
        Am J Cardiol. 2014; 113: 1362-1363
        • Cappato R.
        • Ezekowitz M.D.
        • Klein A.L.
        • Camm A.J.
        • Ma C.S.
        • Le Heuzey J.Y.
        • Talajic M.
        • Scanavacca M.
        • Vardas P.E.
        • Kirchhof P.
        • Hemmrich M.
        • Lanius V.
        • Meng I.L.
        • Wildgoose P.
        • van Eickels M.
        • Hohnloser S.H.
        • on behalf of the X-VeRT Investigators
        Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation.
        Eur Heart J. 2014; 35: 3346-3355
        • Leung D.Y.
        • Black I.W.
        • Cranney G.B.
        • Hopkins A.P.
        • Walsh W.F.
        Prognostic implications of left atrial spontaneous echo contrast in nonvalvular atrial fibrillation.
        J Am Coll Cardiol. 1994; 24: 755-762
        • Kupczynska K.
        • Kasprzak J.D.
        • Michalski B.
        • Lipiec P.
        Prognostic significance of spontaneous echocardiographic contrast detected by transthoracic and transesophageal echocardiography in the era of harmonic imaging.
        Arch Med Sci. 2013; 9: 808-814
        • Zabalgoitia M.
        • Halperin J.L.
        • Pearce L.A.
        • Blackshear J.L.
        • Asinger R.W.
        • Hart R.G.
        Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. Stroke Prevention in Atrial Fibrillation III Investigators.
        J Am Coll Cardiol. 1998; 31: 1622-1626
        • Heidbuchel H.1
        • Verhamme P.
        • Alings M.
        • Antz M.
        • Hacke W.
        • Oldgren J.
        • Sinnaeve P.
        • Camm A.J.
        • Kirchhof P.
        • European Heart Rhythm Association
        European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation.
        Europace. 2013; 15: 625-651