Clinical Performance of Apixaban vs. Vitamin K Antagonists in Patients with Atrial Fibrillation Undergoing Direct Electrical Current Cardioversion: A Prospective Propensity Score-Matched Cohort Study

Direct Current Cardioversion in Atrial Fibrillation Patients on Edoxaban Therapy Versus Vitamin K Antagonists: a Real-world Propensity Score–Matched Study

“…Moreover, our study showed a low incidence of left atrial thrombus revealed by TEE in AF patients on edoxaban therapy (0.7%), similar to that observed in the VKA study group (0.7%), but lower than those reported by ENSURE-AF prospective randomized study [16], in which the authors identified left atrial appendage thrombus by TEE in 47 patients (8%) in the edoxaban group and in 42 patients (7.1%) in the enoxaparin-warfarin group. The low left atrial thrombus incidence reported by the present study was similar to those reported by previous real-world studies analyzing dabigatran (0.6%) and apixaban (0.5%) clinical performances in AF patients undergoing DCC [11,13]. These results may be explained by the different clinical characteristics of our study population compared with those of previous randomized clinical trials (RCTs); our study population showed that mean CHA 2 DS 2 -VASc score values were lower (2.1 ± 0.6 in EDO group vs 2.2 ± 0.4 in VKA group) than those (([2-6 (SD 1•4)) reported by Ensure [16], and similar to values reported by other previous real-world experiences [11,13].…”

“…The low left atrial thrombus incidence reported by the present study was similar to those reported by previous real-world studies analyzing dabigatran (0.6%) and apixaban (0.5%) clinical performances in AF patients undergoing DCC [11,13]. These results may be explained by the different clinical characteristics of our study population compared with those of previous randomized clinical trials (RCTs); our study population showed that mean CHA 2 DS 2 -VASc score values were lower (2.1 ± 0.6 in EDO group vs 2.2 ± 0.4 in VKA group) than those (([2-6 (SD 1•4)) reported by Ensure [16], and similar to values reported by other previous real-world experiences [11,13]. The presence of left atrial appendage thrombus at TEE in two patients with thromboembolic risk (CHA 2 DS 2 -VASc score ≥ 4) and moderate renal impairment (GFR < 40 mL/min) supports the hypothesis that these factors might be considered predictors of left atrial thrombus in the real-world setting [11,13,19,20].…”

“…Cardioversion (both electric and pharmacological) in AF patients is associated with an increased risk of thromboembolic events [1,2] and an adequate level of periprocedural anticoagulation is essential to reduce this risk. The use of direct oral anticoagulants (DOACs) in clinical practice is rapidly increasing [3][4][5][6][7][8][9], even in the setting of patients with AF undergoing electrical cardioversion [10][11][12][13], and the current guidelines recommend initiating anticoagulation with DOACs as soon as possible before every cardioversion of AF [14,15]. For patients with AF of > 48-h duration, the current recommendation is to start oral anticoagulation at least 3 weeks before cardioversion and continue it for at least 4 weeks afterwards.…”

<p>Apixaban in a Morbid Obese Patient with Atrial Fibrillation: A Clinical Experience Using the Plasmatic Drug Evaluation</p>

“…The evaluation of apixaban serum level at peak and trough time demonstrated the therapeutic drug levels in our morbid obese patient and the stability of apixaban plasma levels even when the patient has lost weight. The use of plasma level monitoring for NOAC doseadjustment is discouraged for the vast majority of patients due to the lack of outcome data to support such an approach; however, in rare cases of potentially substantial drug-drug interactions; 23,24 in special population in which the use of NOACs is still debated, 25,26 or in case of not deferrable cardiac or non-cardiac interventional or surgical procedures, 27 a "patient-centered approach", including the plasmatic drug evaluation, might be considered for choosing the more appropriate anticoagulant molecule.…”

Thromboembolic Events Following Atrial Fibrillation Cardioversion and Ablation: What’s the Culprit?

“…It has been recognized that CV is related to thromboembolic events “per se”, independently by the ablation procedure. In patients undergoing TEE-guided cardioversion, patients on direct oral anticoagulants (DOACs), such as dabigatran and apixaban, experienced low incidence of thromboembolic events during follow-ups (0.6% and 1.1%, respectively), similar to warfarin, with a favorable trend of bleeding safety profile [10,11]. The highest risk period after CV is the following week, which would be a suitable timeline for our patient considering the stroke and the peripheral embolism.…”