Background
Rate control medications are foundational in the management of persistent atrial fibrillation (AF). There are no guidelines for adjusting these medications prior to elective direct-current cardioversion (DCCV).
Objective
To derive and validate a preprocedural medication adjustment protocol that maintains peri-DCCV rate control and minimizes risk of postconversion bradycardia, pauses, need for pacing, and cardiopulmonary resuscitation (CPR).
Methods
Consecutive patients with persistent AF awaiting elective DCCV across 2 hospitals were screened for inclusion into derivation, validation, and control cohorts. In the derivation cohort, each patient taking an atrioventricular (AV) nodal blocker had medications adjusted based on heart rate (HR) 2 days before DCCV, and the magnitude of dose adjustment was compared with peri-DCCV HR. The adjustment protocol that achieved the highest percentage of optimal peri-DCCV rate control was tested prospectively in the validation cohort and compared to a standard-of-care control group.
Results
The optimal protocol from the derivation cohort (n = 71), based on the 2-day pre-DCCV HR, was to (1) CONTINUE AV nodal blocker for HR ≥ 100 beats per minute (bpm), (2) reduce dose by ONE increment when 80–99 bpm, (3) reduce dose by TWO increments when 60–79 bpm, and (4) HOLD when <60 bpm. In the prospective validation cohort (n = 106), this protocol improved peri-DCCV rate control (82% vs 62%,
P
< .001) compared to current standard of care (n = 107). There were no conversion pauses ≥5 seconds, need for pacing, or CPR post-DCCV.
Conclusion
This simple preprocedural medication adjustment protocol provides an effective strategy of optimizing peri-DCCV rate control in patients with AF.
BACKGROUND: Retrospective studies have shown that AF patients frequently discontinue, switch, or are non-adherent with oral anticoagulants (OAC). Few studies have explored AF patients' experiences with therapy and their behavior. This study characterized OAC persistence, switching, self-reported adherence, and therapy satisfaction in AF patients. METHODS AND RESULTS: Prospective cohort study involving telephone interviews every 3-4 months of AF patients from five specialized AF clinics in BC. We enrolled 388 patients [41% female, mean age 69 years (SD 10), CCS-SAF score 1.7 (SD 1.2), CHA2DS2-VASc 2.7 (SD 1.5), HAS-BLED 1.4 (SD 1.1)] and followed them for median 14.1 months/patient. Data was analyzed for the 357 participants who completed at least one follow up visit. Index OACs were rivaroxaban (38%), apixaban (28%), warfarin (25%), and dabigatran (9%). Permanent discontinuation or switches occurred in 55 participants (15%), and involved 25 discontinuations (rivaroxaban 10/133, dabigatran 2/33, apixaban 8/100, warfarin 5/91; no between-group differences) and
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.