title: Novel Oral Anticoagulants for DC Cardioversion Procedures: Utilization and Clinical Outcomes Compared with Warfarin.
abstract: BACKGROUND
  Novel oral anticoagulant (NOAC) agents dabigatran, rivaroxaban, and apixaban are increasingly utilized as thromboembolic prevention for patients with atrial fibrillation undergoing direct current cardioversion (DCCV) with post hoc analyses of clinical trials suggesting satisfactory safety and efficacy. This study characterizes utilization, effectiveness, and complications of NOAC agents for stroke prophylaxis in the setting of DCCV.
  
  
  METHODS
  Comparison of warfarin and NOAC agents as periprocedural anticoagulation for DCCV procedures performed at Cleveland Clinic from January 2009 through December 2013. Variables of interest include utilization rates for each NOAC agent stratified by clinical parameters including CHADS2 score, and associated clinical outcomes including cerebrovascular accident (CVA), transient ischemic attack (TIA), peripheral arterial embolism (PAE), and bleeding events during 8 weeks of postprocedure follow-up.
  
  
  RESULTS
  Among 5,320 DCCV procedures, 673 (12.6%) cases were excluded due to inadequate follow-up. Warfarin was utilized in 3,721 (80.1%), dabigatran in 719 (15.5%), rivaroxaban in 159 (3.4%), and apixaban in 48 (1.0%) with a steady increase in NOAC utilization from 2011 to 2013. There were low rates of CVA/TIA (warfarin: 0.97% vs NOAC 1.62%, P = 0.162) and bleeding (warfarin: 1.02% vs NOAC: 0.5%, P = 0.247) and no significant differences detected between agents. Higher CHADS2 /CHA2 DS2 -VASC scores were associated with thromboembolic and bleeding risk. Increasing age, chronic kidney disease, diabetes, coronary disease, and deep vein thrombosis/pulmonary embolism were associated with increased bleeding risk.
  
  
  CONCLUSIONS
  In a high-volume, single-center experience, NOAC utilization has grown to account for over a third of cardioversion procedures, and these agents appear safe and effective compared to warfarin with low rates of thromboembolic and bleeding complications.
authors.affiliation: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Corey M
authors.initials: CM
authors.lastname: Coleman
authors.affiliation: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Shaden
authors.initials: S
authors.lastname: Khalaf
authors.affiliation: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Steven
authors.initials: S
authors.lastname: Mould
authors.affiliation: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Oussama
authors.initials: O
authors.lastname: Wazni
authors.affiliation: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Kanj
authors.affiliation: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Walid
authors.initials: W
authors.lastname: Saliba
authors.affiliation: From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Daniel
authors.initials: D
authors.lastname: Cantillon
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage*; D000069604:Dabigatran / Q000008:administration & dosage; D017147:Defibrillators, Implantable; D005260:Female; D006470:Hemorrhage / Q000517:prevention & control; D006801:Humans; D002546:Ischemic Attack, Transient / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control*; D011720:Pyrazoles / Q000008:administration & dosage; D011728:Pyridones / Q000008:administration & dosage; D000069552:Rivaroxaban / Q000008:administration & dosage; D020521:Stroke / Q000517:prevention & control; D013923:Thromboembolism / Q000517:prevention & control; D016896:Treatment Outcome; D014859:Warfarin / Q000008:administration & dosage*
chemical_list: D000925:Anticoagulants; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D014859:Warfarin; D000069552:Rivaroxaban; D000069604:Dabigatran
keywords: apixaban; atrial arrhythmias; atrial fibrillation; cardioversion; dabigatran; oral anticoagulation; rivaroxaban; stroke prophylaxis; warfarin