Anticoagulation before and after cardioversion; which and for how long

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1 Anticoagulation before and after cardioversion; which and for how long Sameh Samir, MD Cardiovascular medicine dept. Tanta faculty of medicine Atrial fibrillation goals of management Identify and treat underlying structural heart disease and other predisposing conditions. Relieve symptoms. Improve functional capacity/quality of life Reduce morbidity/mortality associated with AF Prevent tachycardia-induced cardiomyopathy Reduce/prevent emergency room visits or hospitalizations secondary to AF/AFL Prevent stroke or systemic thromboembolism 1

predisposing conditions. Relieve symptoms.

2 Rate or rhythm control. Anticoagulation. Cardioversion Rhythm control treatment to restore sinus rhythm. Two types : 1. pharmacological. 2. electrical. Associated with 7 % thromboembolic events without anticoagulation. 2

3 Thromboembolism and cardioverison 1) The presence of thrombus in the left atrial appendage at the time of cardioversion as a result of a reduced flow.. 2) Atrial stunning a paradoxical decrease of left atrial and left atrial appendage function immediately after successful cardioversion to sinus rhythm which leads to thrombus formation. 3

. 2) Atrial stunning a paradoxical decrease of left atrial and left atrial appendage

4 Am j cardiol Am j cardiol1998 Am j cardiol1998 Am J CARDIOL 1998 j cardiol 1998 TEE and cardioversion Exclude the presence of thrombus allows cardioversion without pre anticoagulation. In cases where rapid cardioversion is indicated and high bleeding risk. 4

thrombus allows cardioversion without pre anticoagulation.

5 Which anticoagulant? 5

6 Warfarin and stroke prevention in A.F Antiplatelet drugs vs warfarin in stroke prevention in atrial fibrillation Hart, R et al., Ann Intern Med. 2007;146:

7 INR at time of cardioversion should be 2.5 Ischaemic stroke Intracranial bleeding International normalized ratio Hylek EM. N Engl J Med 1996;335:540-6 Warfarin disadv. Narrow therapeutic range. Continuous follow up. Food and drug interaction. Genetic variation. 7

0 7.0 8.0 International normalized ratio Hylek EM.

8 Coagulation Cascade Intrinsic Pathway (Contact Activation) XII XI Extrinsic Pathway (Tissue Factor) IX Tissue Factor VIII VII VKAs X Factor Xa Inhibitors (-AT) Apixaban and Rivaroxaban V II Direct Thrombin Inhibitors Dabigatran Fibrinogen Fibrin Clot. New oral anticoagulant Freek W A Verheugt, Christopher B Granger, the lancet

Apixaban and Rivaroxaban V II Direct Thrombin Inhibitors Dabigatran Fibrinogen

9 RR (95% CI) of all treatment arms vs warfarin for the overall composite outcome including ischemic stroke + systemic embolism + myocardial infarction + hemorrhagic stroke + adjusted major bleeding Renda G. et al. ESC Congress 2014 presentation 9

embolism + myocardial infarction + hemorrhagic stroke +

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13 X-TRA Study Rationale and design of a study exploring the efficacy of once-daily oral rivaroxaban (X- TRA) on the outcome of left atrial/left atrial appendage thrombus in nonvalvular atrial fibrillation or atrial flutter and a retrospective observational registry providing baseline data (CLOT-AF) Gregory Y.H. Lip, MD, Christoph Hammerstingl, MD, Francisco Marin, MD, Riccardo Cappato, MD, Isabelle Ling Meng, MD, PhD, Bodo Kirsch, MSc, Eolo Morandi, MD, Martin van Eickels, MD, Ariel Cohen, MD, PhD American Heart Journal Volume 169, Issue 4, Pages e2 (April 2015) DOI: /j.ahj Open-label, interventional study Objective: To explore the efficacy of rivaroxaban 20 mg once daily on the resolution of thrombi in subjects with non-valvular AF or atrial flutter who have a LA/LAA thrombus confirmed by TEE. A retrospective registry in the same centres will provide historical data on standard of care treatment American Heart Journal , e2DOI: ( /j.ahj ) 13

Lip, MD, Christoph Hammerstingl, MD, Francisco Marin, MD, Riccardo Cappato, MD, Isabelle Ling Meng, MD, PhD, Bodo Kirsch, MSc, Eolo Morandi, MD, Martin van Eickels, MD, Ariel Cohen, MD, PhD American

14 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation Developed in Collaboration with the Society of Thoracic Surgeons American College of Cardiology Foundation and American Heart Association Prevention of Thromboembolism Recommendations COR LOE For patients with AF or atrial flutter of 48 hours duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0) is recommended for at least 3 weeks before and 4 weeks after cardioversion, regardless of the CHA 2 DS 2 -VASc score and the method (electrical or pharmacological) used to restore sinus rhythm. I B For patients with AF or atrial flutter of more than 48 hours duration or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated. For patients with AF or atrial flutter of less than 48 hours duration and with high risk of stroke, intravenous heparin or LMWH, or administration of a factor Xa or direct thrombin inhibitor, is recommended as soon as possible before or immediately after cardioversion, followed by longterm anticoagulation therapy. I I C C 14

unknown, anticoagulation with warfarin (INR 2.0 to 3.

15 Prevention of Thromboembolism (cont d) Recommendations COR LOE Following cardioversion for AF of any duration, the decision about long-term anticoagulation therapy should be based on the I C thromboembolic risk profile. For patients with AF or atrial flutter of 48 hours duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform TEE before cardioversion and proceed with IIa B cardioversion if no LA thrombus is identified, including in the LAA, provided that anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks. For patients with AF or atrial flutter of 48 hours duration or longer or when duration of AF is unknown, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for at least 3 weeks before and 4 weeks after cardioversion. IIa C Prevention of Thromboembolism (cont d) Recommendations COR LOE For patients with AF or atrial flutter of less than 48 hours duration who are at low thromboembolic risk, anticoagulation (intravenous heparin, LMWH, or a new oral anticoagulant) or no antithrombotic therapy may be considered for cardioversion, without the need for postcardioversion oral anticoagulation. IIb C 15

For patients with AF or atrial flutter of 48 hours duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform TEE before

16 Conclusion 1. Anticoagulation is a must in all A.F patients managed by cardioversion. 2. VKA for at least 3 weeks before cardioversion and 4 weeks after with INR After 4 weeks each patient should be evaluated based oncha 2 DS 2 -VASc score for long term anticoagulation. 4. TEE to exclude LA thrombus is reasonable alternative to pre cardioversion anticoagulant 5. Post hoc analysis showed that NOAGS is safe and effective in cardioverison. 6. NOAG could make the precardioverison anticoagulation time more shorter. 16

4. TEE to exclude LA thrombus is reasonable alternative to pre cardioversion anticoagulant 5.

17 THANK YOU. 17

Anticoagulants in Atrial Fibrillation

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