Cardioverting acute atrial fibrillation and the risk of thromboembolism: not all patients are created equal

Abstract

Current guidelines support the well-established clinical practice that patients who present with atrial fi brillation (AF) of less than 48 hours duration should be considered for cardioversion, even in the absence of pre-existing anticoagulation. However, with increasing evidence that short runs of AF confer signifi cant risk of stroke, on what evidence is this 48-hour rule based and is it time to adopt a new approach? We review existing evidence and suggest a novel approach to risk stratifi cation in this setting. Overall, the risk of thromboembolism associated with acute cardioversion of patients with AF that is estimated to be of <48 hours duration is low. However, this risk varies widely depending on patient characteristics. From existing evidence, we show that using the CHA 2 DS 2 -VASc score may allow better selection of appropriate patients in order to prevent exposing specifi c patient groups to an unacceptably high risk of a potentially devastating complication. KEYWORDS : Anticoagulants , atrial fi brillation , cardioversion , electrical cardioversion , stroke , thromboembolism IntroductionInternational guidelines support the well-established clinical practice that patients who present with non-valvular atrial fibrillation (AF) of less than 48 hours duration should be considered for cardioversion, even in the absence of pre-existing anticoagulation.1,2 The risk with more prolonged periods of AF is that restoration of sinus rhythm may precipitate embolism of intra-atrial thrombus causing stroke. However, with increasing evidence that even short runs of AF confer significant risk of stroke, [3][4][5][6] this review examines the evidence supporting the '48-hour rule' and suggests a novel approach to risk stratification in this setting. Search strategy and selection criteriaData for this review were identified by searches of PubMed using combinations of the terms 'atrial fibrillation', 'cardioversion' and 'thromboembolism'. References sourced ABSTRACTCardioverting acute atrial fi brillation and the risk of thromboembolism: not all patients are created equal from relevant articles were also included. Additional references were identified from review of current international guidelines on the management of atrial fibrillation.

Relationship among atrial fibrillation, the CHA2DS2-VASc score and ischaemic stroke in patients with coronary artery disease: a propensity score matching study in Hebei, China

“…Regardless of the CHA 2 DS 2 -VASc score and the method used to restore the sinus rhythm, cardioversion can be performed without anticoagulation. However, whether the 48-h threshold applies to all patients with AF is debatable [ 25 ]. In addition, a brief episode of subclinical AF doubled the risk of ischaemic stroke in elderly patients [ 26 ].…”

Paroxysmal Atrial Fibrillation: Insight Into the Intimate Mechanisms of Coagulation

“…The "48-h rule" is well established in clinical practice, according to which early cardioversion (up to 48 h of arrhythmia) is safe with a low thromboembolic risk ranging between 0.3% and 1.1% [32]. That is why early IV anticoagulant therapy is currently recommended.…”

“…Clini-Negreva et al Cardiol Res. 2020;11(1): [22][23][24][25][26][27][28][29][30][31][32] cal evidence indicates that, although lower, thrombotic risk is observed not only in the persistent form of the disease but also in paroxysmal atrial fibrillation (PAF). This determines the scientific and clinical interest in coagulation changes occurring in short episodes of the disease.…”

Relationship Among Atrial Fibrillation, CHADS2 Score and Ischaemic Stroke in Patients With Coronary Artery Disease: A Propensity Score Matching Study

“…Regardless of the CHA 2 DS 2 -VASc score and the method used to restore the sinus rhythm, cardioversion can be performed without anticoagulation. However, whether the 48-hour threshold applies to all patients with AF is debatable [18]. In addition, a brief episode of subclinical AF doubles the risk of ischaemic stroke in elderly patients [19].…”