title: Rapid achievement of therapeutic anticoagulation positively affects outcome in patients undergoing cardioversion for persistent atrial fibrillation.
abstract: BACKGROUND
  Current guidelines recommend anticoagulation with warfarin with documentation of an International Normalized Ratio (INR) of 2-3 for 3 weeks prior to cardioversion of persistent atrial fibrillation (AF). Achievement of adequate anticoagulation often takes longer than 3 weeks, increasing the time to cardioversion.
  
  
  OBJECTIVE
  The goal of the study was to quantify the total time elapsed for adequate anticoagulation and to identify differences in time to cardioversion between patients managed by primary care physicians (PCP) compared with those enrolled in a structured anticoagulation clinic (AC). Finally, we assessed the effect on treatment outcome between groups.
  
  
  METHODS
  A retrospective chart review identified those patients undergoing elective cardioversion who were started on warfarin at our medical center since 1997. The venue of anticoagulation management, time for adequate maintenance of INR, and total time to cardioversion were recorded. A comparison was made between the two groups to identify the effect on treatment outcome. Multivariate analysis was performed to evaluate any effect comorbidities may have played on maintenance of normal sinus rhythm (NSR) within the treatment groups.
  
  
  RESULTS
  Of 83 patients, 48 had warfarin therapy monitored at their PCP and 35 were managed at our AC. Average time to therapeutic INR at AC and PCP was 29.1 +/- 9.3 and 50.7 +/- 6.8 days, respectively (p = 0.026). Average time to cardioversion at AC and PCP was 60.6 +/- 11.2 and 88.7 +/- 18.5 days (p = 0.041). At 12 months post cardioversion, 30 of 83 patients maintained NSR. Nineteen of 35 patients (54.3%) managed at AC maintained NSR compared with 11 of 48 patients (22.9%) managed at PCP (RR 0.61, 95% confidence interval 0.45-0.84) (p = 0.015).
  
  
  CONCLUSIONS
  Therapeutic anticoagulation is more quickly achieved in a specialty anticoagulation clinic than at a PCP and positively affects therapy outcome.
authors.affiliation: University of Florida, Division of Cardiovascular Medicine, College of Medicine, Clinical Electrophysiology Section, Gainesville, Florida 32610, USA. raycutro@hotmail.com
authors.forename: Ray
authors.initials: R
authors.lastname: Cutro
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Burkart
authors.forename: Anne B
authors.initials: AB
authors.lastname: Curtis
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000628:therapy*; D003131:Combined Modality Therapy; D004554:Electric Countershock; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011292:Premedication / Q000592:standards*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014859:Warfarin / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D014859:Warfarin