CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 3, July/August 2023 AFRICA 181 Electric cardioversion in patients treated with oral anticoagulants: embolic material in the left atrial appendage Jarosław Karwowski, Jerzy Rekosz, Mateusz Solecki, Renata Mączyńska-Mazuruk, Karol Wrzosek, Joanna Sumińska-Syska, Mirosław Dłużniewski Abstract Atrial fibrillation (AF) remains the most common arrhythmia. The sinus rhythm restoration procedure without adequate anticoagulant preparation may lead to a thromboembolic event in approximately 5–7% of patients. The initiation of oral anticoagulation significantly reduces this risk by inhibiting formation of embolic material in the heart cavities, especially in the left atrial appendage (LAA). However, there is a group of patients who develop embolic material in the LAA despite oral anticoagulation treatment. The best treatment method to dissolve thrombus in the LAA is not clear, due to the lack of studies with adequate power and endpoints that can determine the best management strategy. We present clinical trials comparing the efficacy and safety of oral anticoagulants in patients undergoing AF cardioversion. We evaluate the frequency of LAA thrombus formation in patients with AF on treatment with oral anticoagulants. Furthermore, we discuss the effectiveness of various treatment strategies on LAA thrombus resolution. Keywords: electric cardioversion, atrial fibrillation, left atrial appendage thrombus, transoesophageal echocardiography, nonvitamin K antagonist oral anticoagulants Submitted 16/2/22, accepted 14/11/22 Published online 5/12/22 Cardiovasc J Afr 2023; 34: 181–188 www.cvja.co.za DOI: 10.5830/CVJA-2022-060 Atrial fibrillation (AF) is the most common type of arrhythmia. AF is associated with a 1.5- to 1.9-fold increase in the risk of mortality and a two- to five-fold increase in the risk of thromboembolic events, including stroke, transient ischaemic attack (TIA) and systemic embolism.1 Restoration of heart rhythm control remains an integral part of the treatment for this type of arrhythmia. Electric cardioversion (ECV) is associated with an increased risk of embolism with embolic material existing in the heart cavities.2,3 The sinus rhythm restoration procedure without adequate anticoagulation preparation may lead to a thromboembolic event in about 5–7% of patients.4 The initiation of oral anticoagulation with a vitamin K antagonist (VKA) at least three weeks before cardioversion and continuation of this treatment for a minimum of four weeks after the procedure may reduce the risk of a thromboembolism.5-7 Among patients permanently treated with an oral VKA, ad hoc ECV may be attempted if the efficacy of this treatment is proven by the therapeutic outcome of the international normalised ratio (INR).1 However, in the group treated with novel oral anticoagulants (NOACs), cardioversion can be performed when the patient confirms regular intake of these drugs. In the era of the increasingly common use of NOACs, the question remains whether they are an effective and safe alternative. Furthermore, should an electrical cardioversion attempt be preceded by a transoesophageal echocardiogram (TEE), despite chronic anticoagulation? Electric cardioversion among patients treated with NOACs In recent years, the results of three prospective, randomised trials comparing the efficacy and safety of NOAC versus heparin/VKA in patients undergoing electrical cardioversion were published, the X-VeRT trial with rivaroxaban, the ENSURE-AF trial with edoxaban, and the EMANATE trial with apixaban.8-10 In the X-VeRT trial, 1 504 patients with AF of unknown duration or lasting more than 48 hours were randomised into two groups, those receiving rivaroxaban once daily (20 or 15 mg depending on creatinine clearance) or those receiving VKAs in a 2:1 ratio.8 The incidence of stroke, systemic embolism, myocardial infarction and cardiovascular death was low (between 0.5 and 1%), which was comparable for NOAC and VKA in the 30-day Department of Heart Diseases, Postgraduate Medical School, Warsaw, Poland Jarosław Karwowski, PhD, karwowski.jarek@gmail.com Renata Mączyńska-Mazuruk, PhD Karol Wrzosek, PhD Joanna Sumińska-Syska, PhD Mirosław Dłużniewski, PhD II Department of Cardiology, Masovian Brodnowski Hospital, Warsaw, Poland Jerzy Rekosz, PhD Mateusz Solecki, PhD Review Article
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