title: Overtreatment and undertreatment with anticoagulation in relation to cardioversion of atrial fibrillation (the RHYTHM-AF study).
abstract: Antithrombotic therapy is central to the management of atrial fibrillation. This analysis from the RHYTHM-atrial fibrillation (RHYTHM-AF) registry explored the appropriateness of antithrombotic therapy in relation to stroke risk and atrial fibrillation duration in patients with atrial fibrillation. RHYTHM-AF, a prospective multinational registry, enrolled consecutive adult patients with atrial fibrillation considered for cardioversion. We compared the type of antithrombotic therapy administered at the time of cardioversion and at discharge with stroke risk ("high stroke risk" defined by CHA2DS2-VASc >1) and duration of atrial fibrillation (≤48 vs >48 hours or unknown duration). Of 2,972 patients who were cardioverted (34.5% through pharmacologic cardioversion [PCV] and 65.5% through electrical cardioversion [ECV]), 65% were at high risk of stroke and 30% presented with atrial fibrillation of >48-hour or unknown duration. At the time of PCV and ECV, 36% (n = 242) and 84% (n = 1,075) of high-risk patients, respectively, were taking vitamin K antagonists or heparin. At discharge, these rates increased to 62% (n = 414) and 93% (n = 1,191), respectively. Of all low-stroke risk patients with short-duration atrial fibrillation undergoing PCV (n = 260) and ECV (n = 111), 7% (n = 17) and 30% (n = 33), respectively, were taking vitamin K antagonists or heparin at the time of cardioversion. At discharge, these rates increased to 19% (n = 50) and 40% (n = 44), respectively. In conclusion, ECV was frequently performed under appropriate antithrombotic therapy for most high-risk patients with atrial fibrillation, whereas PCV was frequently performed without appropriate antithrombotic therapy. To enhance pericardioversion stroke prevention, cardioversion algorithms should focus less on the type of conversion and more on stroke risk factors and atrial fibrillation duration.
authors: University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom. Electronic address: g.y.h.lip@bham.ac.uk.
authors: Gregory Y H
authors: GY
authors: Lip
authors: Herzzentrum Ludwigshafen, Med. Klinik B und Institut f. Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany.
authors: Anselm K
authors: AK
authors: Gitt
authors: Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France.
authors: Jean-Yves
authors: JY
authors: Le Heuzey
authors: Merck & Co., Inc., Whitehouse Station, New Jersey.
authors: Lori D
authors: LD
authors: Bash
authors: Merck & Co., Inc., Whitehouse Station, New Jersey.
authors: Christopher J
authors: CJ
authors: Morabito
authors: Institut f. Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany.
authors: Alexandra A
authors: AA
authors: Bernhardt
authors: Merck & Co., Inc., Whitehouse Station, New Jersey.
authors: Christine McCrary
authors: CM
authors: Sisk
authors: MSD France, Courbevoie, France.
authors: François
authors: F
authors: Chazelle
authors: Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands.
authors: Harry J
authors: HJ
authors: Crijns
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage*; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D001777:Blood Coagulation / Q000187:drug effects; D004305:Dose-Response Relationship, Drug; D017548:Echocardiography, Transesophageal; D004554:Electric Countershock / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011446:Prospective Studies; D020521:Stroke / Q000097:blood / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants