Dabigatran Versus Warfarin for Direct Current Cardioversion in Atrial Fibrillation

Abstract

IntroductionDirect current cardioversion (DCCV) is considered as the most effective treatment for atrial fibrillation (AF). AF is associated with an increased risk of thromboembolism, and DCCV may increase this risk. The current recommendation is, therefore, to anticoagulate for at least 3 weeks before DCCV and 4 weeks after the procedure.MethodsA retrospective study of patients referred for elective DCCV as treatment for AF in Hampshire Hospitals NHS Foundation Trust was performed to compare the safety and efficacy of dabigatran with warfarin in this setting.ResultsDuring a 12-month period, 129 patients were referred for DCCV for the treatment of AF and 107 patients received DCCV. Fifty-four patients were anticoagulated with dabigatran, 42 patients with warfarin, and 11 patients with other direct oral anticoagulants (DOACs) with choice of agent determined following an informed discussion with the patient. The average number of days between the date of referral for DCCV and the date of DCCV for patients who were on dabigatran was 51 days, while for warfarin, this was 82 (P = 0.001). The proportion of cancelation and rescheduling for warfarin patients was 21.4%, while for dabigatran, this was 5.5%. Patients were reviewed 6–20 weeks after DCCV; the success rate of DCCV for dabigatran patients was 61%, whilst for warfarin patients, this was 52%. The success rate went up to 69% for patients who received DCCV within 45 days of referral (P = 0.165).ConclusionThis retrospective study supports clinical experience that DCCV is more likely to be successful when there is a shorter duration between the onset of AF and the date of DCCV, and shows that the use of dabigatran in comparison with warfarin facilitates earlier DCCV.

Direct Oral Anticoagulants in Cardioversion: A Review of Current Evidence

“…Collectively, each of these studies found reductions in time to cardioversion ranging from 18 to 42 days when DOACs were used instead of warfarin. 27,[37][38][39][40] The improved efficiency with DOACs is clinically relevant because shorter duration in AF prior to ECV is a predictor of maintenance in sinus rhythm following cardioversion. 40,41 Pharmacoeconomic studies outside the United States have demonstrated sizable cost savings equivalent to approximately 250 to 500 US dollars per patient when DOACs are used in place of warfarin; the cost savings are largely attributable to reductions in cardioversion delays and laboratory monitoring.…”

“…27,[37][38][39][40] The improved efficiency with DOACs is clinically relevant because shorter duration in AF prior to ECV is a predictor of maintenance in sinus rhythm following cardioversion. 40,41 Pharmacoeconomic studies outside the United States have demonstrated sizable cost savings equivalent to approximately 250 to 500 US dollars per patient when DOACs are used in place of warfarin; the cost savings are largely attributable to reductions in cardioversion delays and laboratory monitoring. 42,43 Although the lack of need for routine laboratory monitoring may be convenient for patients, some providers may view the inability to verify medication adherence and therapeutic levels as a limitation.…”

Contemporary Management of Direct Oral Anticoagulants During Cardioversion and Ablation for Nonvalvular Atrial Fibrillation

“…The X‐VeRT trial reported even shorter times to delayed cardioversion with DOACs, which may be due to the fact that patients on warfarin do not always keep their INR between 2.0 and 3.0 for the 3 weeks prior to cardioversion . These findings are supported by a small study (n=106) that evaluated time to cardioversion for patients receiving dabigatran or warfarin . Mean time to cardioversion for patients on dabigatran was significantly shorter than for patients receiving warfarin (54 days vs 82 days; respectively, p=0.001).…”

“…24 These findings are supported by a small study (n=106) that evaluated time to cardioversion for patients receiving dabigatran or warfarin. 33 Mean time to cardioversion for patients on dabigatran was significantly shorter than for patients receiving warfarin (54 days vs 82 days; respectively, p=0.001). A Danish registry including 1230 patients receiving dabigatran or warfarin also evaluated mean times to cardioversion.…”

Are Three Weeks of Oral Anticoagulation Sufficient for Safe Cardioversion in Atrial Fibrillation?

“…The traditional therapeutic approach to these patients is treatment with parenteral anticoagulants or vitamin K antagonists (VKAs), mostly Warfarin [1,8,12]. The current ESC guidelines also suggest that the direct oral anticoagulants (DOACs) could be as efficient and safer as VKAs, however robust data from randomized clinical trials (RCTs) are lacking [10][11][12][13][14][15][16][17][18][19].…”