Advertisement

Anticoagulation, CHA2DS2VASc Score, and Thromboembolic Risk of Cardioversion of Acute Atrial Fibrillation (from the FinCV Study)

Published:January 28, 2016DOI:https://doi.org/10.1016/j.amjcard.2016.01.024
      The efficacy of the anticoagulation in preventing thromboembolic complications (TEC) and the usefulness of the CHA2DS2VASc score for assessing stroke risk during cardioversion of acute atrial fibrillation (AF) are unclear. Thus, our objectives were to assess the ability of the CHA2DS2VASc score to predict TEC and to evaluate the efficacy of anticoagulation in the prevention of TEC in Finnish CardioVersion (FinCV) study. The FinCV is a retrospective, multicenter study of 3,143 patients, who underwent 7,660 cardioversions for acute AF. The value of the CHA2DS2VASc score in predicting TEC was analyzed separately in cardioversions performed without and with anticoagulation. A total of 40 definite TEC (0.6%) occurred after 7,237 successful cardioversions and 1 stroke (0.2%) after 423 unsuccessful procedures. In 5,362 cardioversions performed without anticoagulation, the risk of definite TEC increased significantly from 0.4% in patients with a CHA2DS2VASc score of 0 to 1 to 2.3% in those with score of ≥5 (p <0.001 for trend). The C-statistic of the CHA2DS2VASc score was 0.72 (0.61 to 0.83) in predicting definite TEC in non-anticoagulated patients with first cardioversion. The incidence of definite TEC was significantly lower in 2,298 cardioversions performed during anticoagulation (0.1% vs 0.7%, p = 0.001), and the preventive effect of anticoagulation was significant in patients with a score of ≥2 (0.2% vs 1.1%, p = 0.001). In conclusion, CHA2DS2VASc score is a strong predictor of TEC in cardioversion of acute AF performed without anticoagulation. Importantly, periprocedural anticoagulation reduced the risk of TEC by 82%. The overall risk of these complications was low after failed cardioversion.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • 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
        • Document Reviewers
        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
        • 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
        Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).
        Eur Heart J. 2010; 31: 2369-2429
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cigarroa J.E.
        • Cleveland Jr., J.C.
        • Conti J.B.
        • Ellinor P.T.
        • Ezekowitz M.D.
        • Field M.E.
        • Murray K.T.
        • Sacco R.L.
        • Stevenson W.G.
        • Tchou P.J.
        • Tracy C.M.
        • Yancy C.W.
        • American College of Cardiology/American Heart Association Task Force on Practice Guidelines
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        J Am Coll Cardiol. 2014; 64: e1-e76
        • 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. 2013; 62: 1187-1192
        • Korkeila P.
        • Mustonen P.
        • Koistinen J.
        • Nyman K.
        • Ylitalo A.
        • Karjalainen P.
        • Lund J.
        • Airaksinen J.
        Clinical and laboratory risk factors of thrombotic complications after pacemaker implantation: a prospective study.
        Europace. 2010; 12: 817-824
        • Airaksinen K.E.
        • Biancari F.
        • Karjalainen P.
        • Mikkola R.
        • Kuttila K.
        • Porela P.
        • Laitio T.
        • Lip G.Y.
        Safety of coronary artery bypass surgery during therapeutic oral anticoagulation.
        Thromb Res. 2011; 128: 435-439
        • Airaksinen K.E.
        • Korkeila P.
        • Lund J.
        • Ylitalo A.
        • Karjalainen P.
        • Virtanen V.
        • Raatikainen P.
        • Koivisto U.M.
        • Koistinen J.
        Safety of pacemaker and implantable cardioverter-defibrillator implantation during uninterrupted warfarin treatment—the FinPAC study.
        Int J Cardiol. 2013; 168: 3679-3682
        • Gronberg T.
        • Nuotio I.
        • Nikkinen M.
        • Ylitalo A.
        • Vasankari T.
        • Hartikainen J.E.
        • Airaksinen K.E.
        Arrhythmic complications after electrical cardioversion of acute atrial fibrillation: the FinCV study.
        Europace. 2013; 15: 1432-1435
        • Nuotio I.
        • Hartikainen J.E.
        • Gronberg T.
        • Biancari F.
        • Airaksinen K.E.
        Time to cardioversion for acute atrial fibrillation and thromboembolic complications.
        JAMA. 2014; 312: 647-649
        • Gronberg T.
        • Hartikainen J.E.
        • Nuotio I.
        • Biancari F.
        • Vasankari T.
        • Nikkinen M.
        • Ylitalo A.
        • Airaksinen K.E.
        Can we predict the failure of electrical cardioversion of acute atrial fibrillation? The FinCV study.
        Pacing Clin Electrophysiol. 2015; 38: 368-375
        • DeLong E.R.
        • DeLong D.M.
        • Clarke-Pearson D.L.
        Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
        Biometrics. 1988; 44: 837-845
        • Lip G.Y.
        • Nieuwlaat R.
        • Pisters R.
        • Lane D.A.
        • Crijns H.J.
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation.
        Chest. 2010; 137: 263-272
        • Bjerkelund C.J.
        • Orning O.M.
        The efficacy of anticoagulant therapy in preventing embolism related to D.C. electrical conversion of atrial fibrillation.
        Am J Cardiol. 1969; 23: 208-216
        • 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
        • Apostolakis S.
        • Haeusler K.G.
        • Oeff M.
        • Treszl A.
        • Andresen D.
        • Borggrefe M.
        • Lip G.Y.
        • Meinertz T.
        • Parade U.
        • Samol A.
        • Steinbeck G.
        • Wegscheider K.
        • Breithardt G.
        • Kirchhof P.
        Low stroke risk after elective cardioversion of atrial fibrillation: an analysis of the Flec-SL trial.
        Int J Cardiol. 2013; 168: 3977-3981
        • Gallagher M.M.
        • Hennessy B.J.
        • Edvardsson N.
        • Hart C.M.
        • Shannon M.S.
        • Obel O.A.
        • Al-Saady N.M.
        • Camm A.J.
        Embolic complications of direct current cardioversion of atrial arrhythmias: association with low intensity of anticoagulation at the time of cardioversion.
        J Am Coll Cardiol. 2002; 40: 926-933
        • 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
        • Stellbrink C.
        • Nixdorff U.
        • Hofmann T.
        • Lehmacher W.
        • Daniel W.G.
        • Hanrath P.
        • Geller C.
        • Mugge A.
        • Sehnert W.
        • Schmidt-Lucke C.
        • Schmidt-Lucke J.A.
        • ACE (Anticoagulation in Cardioversion using Enoxaparin) Study Group
        Safety and efficacy of enoxaparin compared with unfractionated heparin and oral anticoagulants for prevention of thromboembolic complications in cardioversion of nonvalvular atrial fibrillation: the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial.
        Circulation. 2004; 109: 997-1003
        • Hart R.G.
        • Pearce L.A.
        • Aguilar M.I.
        Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.
        Ann Intern Med. 2007; 146: 857-867
        • 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
        • 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
        • Lindberg S.
        • Hansen S.
        • Nielsen T.
        Spontaneous conversion of first onset atrial fibrillation.
        Intern Med J. 2012; 42: 1195-1199
        • Danias P.G.
        • Caulfield T.A.
        • Weigner M.J.
        • Silverman D.I.
        • Manning W.J.
        Likelihood of spontaneous conversion of atrial fibrillation to sinus rhythm.
        J Am Coll Cardiol. 1998; 31: 588-592
        • Weigner M.J.
        • Caulfield T.A.
        • Danias P.G.
        • Silverman D.I.
        • Manning W.J.
        Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting less than 48 hours.
        Ann Intern Med. 1997; 126: 615-620
        • Marcucci M.
        • Lip G.Y.
        • Nieuwlaat R.
        • Pisters R.
        • Crijns H.J.
        • Iorio A.
        Stroke and bleeding risk co-distribution in real-world patients with atrial fibrillation: the Euro Heart Survey.
        Am J Med. 2014; 127: 979-986.e2