title: Quality of anticoagulation with unfractionated heparin plus phenprocoumon for the prevention of thromboembolic complications in cardioversion for non-valvular atrial fibrillation. Sub-analysis from the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial.
abstract: BACKGROUND
  Anticoagulation in cardioversion for atrial fibrillation is performed using unfractionated heparin and oral anticoagulants. TEE-guided cardioversion, after achievement of therapeutic anticoagulation (1-3 days), may be an alternative to the traditional procedure (3-week anticoagulation followed by cardioversion). The quality of anticoagulation in atrial fibrillation has not been investigated in a randomised trial with TEE-guided cardioversion. We analysed respective data from the ACE trial on the quality of conventional anticoagulation, where most participating centres chose the TEE-guided approach.
  
  
  METHODS
  In a randomised, prospective, multicentre trial, we analysed the efficacy of unfractionated heparin plus phenprocoumon in 248 patients on an intention-to-treat basis. There were 2373 evaluable anticoagulation measurements (out of 2925 measurements) and 4 categories of anticoagulation quality (under-, target, over- and severe over-anticoagulation). Of patients with evaluable measurements, 88% received short-term anticoagulation (4 weeks) in TEE-guided cardioversion.
  
  
  RESULTS
  The median time to achieve therapeutic anticoagulation (aPTT> or =60 and <80 s or INR> or =2 and <3) was 3 days. Anticoagulation values were out of therapeutic range in 69.5% of measurements during 4- or 7-week follow-up, and never within therapeutic range in 10% of patients. Of the 15 primary endpoints observed (death, thromboembolism and major bleeding complications), only 3 were in patients with anticoagulation measurements within therapeutic range.
  
  
  CONCLUSIONS
  In this study setting, with predominance of 4 weeks anticoagulation in TEE-guided cardioversion for atrial fibrillation, therapeutic anticoagulation was reached within 3 days using conventional anticoagulation. Despite careful dose adjustments, anticoagulation was out of therapeutic range in almost 70% of total measurements and 80% of primary endpoints.
authors.affiliation: Molecular Cardiology, JW Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany. schmidt-lucke@em.uni-frankfurt.de
authors.forename: Caroline
authors.initials: C
authors.lastname: Schmidt-Lucke
authors.forename: W Dieter
authors.initials: WD
authors.lastname: Paar
authors.forename: Christoph
authors.initials: C
authors.lastname: Stellbrink
authors.forename: Uwe
authors.initials: U
authors.lastname: Nixdorff
authors.forename: Thomas
authors.initials: T
authors.lastname: Hofmann
authors.forename: Jürgen
authors.initials: J
authors.lastname: Meurer
authors.forename: Rolf
authors.initials: R
authors.lastname: Grewe
authors.forename: Werner Günther
authors.initials: WG
authors.lastname: Daniel
authors.forename: Peter
authors.initials: P
authors.lastname: Hanrath
authors.forename: Andreas
authors.initials: A
authors.lastname: Mügge
authors.forename: Helmut U
authors.initials: HU
authors.lastname: Klein
authors.forename: Jan André
authors.initials: JA
authors.lastname: Schmidt-Lucke
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D015331:Cohort Studies; D004554:Electric Countershock; D017984:Enoxaparin / Q000008:administration & dosage*; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D019934:International Normalized Ratio; D010314:Partial Thromboplastin Time; D010644:Phenprocoumon / Q000494:pharmacology*; D011446:Prospective Studies; D013923:Thromboembolism / Q000188:drug therapy* / Q000517:prevention & control*; D013997:Time Factors
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin; D006493:Heparin; D010644:Phenprocoumon