title: Efficacy of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation at 6 months: a randomized controlled trial.
abstract: BACKGROUND
  Electrical cardioversion in patients with atrial fibrillation (AF) is associated with an increased risk of stroke. We compared a transesophageal echocardiography (TEE)-guided strategy with a conventional strategy in patients with AF > 2 days' duration undergoing electrical cardioversion over a 6-month follow-up.
  
  
  METHODS
  The ACUTE study was a multicenter, randomized, clinical trial, with 1222 patients. Six-month follow-up was available in 1034 patients (85%), 525 in the TEE group and 509 in the conventional group. The primary composite end points were cerebrovascular accident, transient ischemic attack, and peripheral embolism at 6 months, which was a prespecified time point. Secondary end points were hemorrhage, mortality, and sinus rhythm.
  
  
  RESULTS
  At 6 months, there was no difference in composite embolic events between the TEE group and the conventional group (10 [2%] vs 4 [0.8%]; risk ratio (RR) 2.47, 95% CI 0.78-7.88; P = .11). However, the hemorrhagic rate was significantly lower in the TEE group (23 [4.4%] vs 38 [7.5%]; RR 0.58, 96% CI 0.35-0.97; P = .04). There was no difference between the 2 treatment groups in all-cause mortality (21 [4%] vs 14 [2.8%]; RR 1.48, 95% CI 0.76-2.92; P = .25) and in the occurrence of normal sinus rhythm between the 2 groups (305 [62.2%] vs 280 [58.1%]; P = .51). Sinus rhythm at 6 months was more common in the TEE-guided group, in those patients who had direct current cardioversion (238 [62.5%] vs 151 [53.9%]; P = .03).
  
  
  CONCLUSIONS
  The TEE-guided strategy may be considered a clinically effective alternative to a conventional anticoagulation strategy for patients with AF of > 2 days' duration undergoing electrical cardioversion over a 6-month period.
authors.affiliation: Cleveland Clinic Foundation, Cleveland, OH 44195, USA. kleina@ccf.org
authors.forename: Allan L
authors.initials: AL
authors.lastname: Klein
authors.forename: Richard A
authors.initials: RA
authors.lastname: Grimm
authors.forename: Susan E
authors.initials: SE
authors.lastname: Jasper
authors.forename: R Daniel
authors.initials: RD
authors.lastname: Murray
authors.forename: Carolyn
authors.initials: C
authors.lastname: Apperson-Hansen
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Lieber
authors.forename: Ian W
authors.initials: IW
authors.lastname: Black
authors.forename: Ravin
authors.initials: R
authors.lastname: Davidoff
authors.forename: Raimund
authors.initials: R
authors.lastname: Erbel
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Halperin
authors.forename: David A
authors.initials: DA
authors.lastname: Orsinelli
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Porter
authors.forename: Marcus F
authors.initials: MF
authors.lastname: Stoddard
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000401:mortality / Q000628:therapy*; D017548:Echocardiography, Transesophageal; D004554:Electric Countershock / Q000379:methods*; D004617:Embolism / Q000209:etiology* / Q000401:mortality; D005260:Female; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D020521:Stroke / Q000209:etiology; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000379:methods
chemical_list: D000925:Anticoagulants