Advances in anticoagulation management of patients undergoing cardioversion of nonvalvular atrial fibrillation

Summary

Atrial fibrillation (AF) is a major cause of stroke. The restoration of sinus rhythm through cardioversion, either chemical or electrical is a common practice. Interestingly, there is an incremental increase from the baseline risk for embolisation in the immediate post-cardioversion period, with most events occurring within 10 days from cardioversion. Especially patients with recent onset AF show the lowest rates of antithrombotic therapy, while having a high stroke risk. Despite the increased risk for embolisation, anticoagulation in patients undergoing cardioversion of atrial fibrillation is often inadequate. Moreover, since the implementation of non-vitamin K antagonists oral anticoagulants (DOACs) there are several therapeutic approaches for pericardioversion anticoagulant therapy and not all suits to all patients. In addition, the extensive use of transesophageal echocardiography provides an alternative strategy, especially useful for patients of high haemorrhagic risk. In this review article, we aim to provide an update on the anticoagulation strategies for patients undergoing cardioversion of non-valvular atrial fibrillation in the advent of the use of DOACs.

Zusammenfassung

Vorhofflimmern (VHF) ist eine der Hauptursachen für Schlaganfall. Die Wiederherstellung des Sinusrhythmus durch Kardioversion, entweder chemisch oder elektrisch, ist gängige Praxis. Interessanterweise steigt das Base - line-Embolierisiko unmittelbar nach Kardioversion schrittweise an, wobei die meisten Ereignisse innerhalb von 10 Tagen danach auftreten. V. a. Patienten mit neu aufgetretenem VHF haben die niedrigsten Raten an anti thrombotischer Therapie bei gleichzeitig hohem Schlaganfallrisiko. Ungeachtet des erhöhten Embolierisikos ist die Antikoagulation bei Patienten, die wegen VHF kardiovertiert werden, häufig unzureichend. Zudem gibt es seit der Einführung der nicht-Vitamin-K-antagonistischen direkten oralen Antikoagulantien (DOAK) mehrere therapeutische Ansätze für eine gerinnungshemmende Behandlung vor und nach der Kardioversion, aber nicht jeder Ansatz ist für alle Patienten geeignet. Die transösophagealen Echokardiographie ist eine alternative Strategie, v. a.für Patienten mit hohem Blutungsrisiko. In dieser Übersicht beschreiben wir den aktuellen Stand des Wissens zu antikoagulatorischen Strategien für Patienten, die wegen eines nicht valvulären VHF kardiovertiert werden.

Keywords

atrial fibrillation - cardioversion - anticoagulant therapy - transoesophageal echocardiography

Schlüsselwörter

Vorhofflimmern - Kardioversion - antikoagulative Therapie - transösophageale Echokardiographie

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