Charlène , Ghassan , Mathilde , Damien , Jean-Guillaume , and Alain: Clinical experience of dabigatran and rivaroxaban in electrical cardioversion of atrial fibrillation.

Electrical cardioversion (ECV) can improve quality of life in symptomatic patients with atrial fibrillation (AF). Resumption of sinus rhythm is associated with an increased risk of thromboembolism and anticoagulation is mandatory for at least 3 weeks before (except in case of the alternative transesophageal echocardiography (TEE)-guided strategy) and 4 weeks after cardioversion1,2. Novel oral anticoagulants (NOACs) are an alternative to vitamin K antagonists for reducing thromboembolic risk but data on their use in the setting of ECV is still limited. The goal of this study was to evaluate the efficacy and safety of NOACs in consecutive patients undergoing elective ECV for AF.

We performed a monocentric retrospective study of all patients who underwent ECV on dabigatran or rivaroxaban between January 2012 and December 2014 at our institution. A TEE was performed to exclude left atrial thrombus in patients with less than 3 weeks of anticoagulation before ECV, in case of imperfect drug compliance, or at physician discretion. Clinical follow-up at 30 days was obtained through review of electronic medical records or by telephone interview with the patients.

Fifty-two patients were scheduled for ECV during the study period, including 29 on dabigatran and 23 on rivaroxaban. TEE was performed in 41 (79%) patients, revealing left atrial appendage thrombus in 2 (5%) patients and spontaneous contrast in 19 (45%) patients. The characteristics of the 2 patients with intra-atrial thrombus are presented in Table 1. Their CHA2DS2-VASC scores were 0 and 2. These patients were contra-indicated for ECV.

ECV was performed in 50 patients (41 men and 9 women) including 28 on dabigatran and 22 on rivaroxaban. Mean age of 65 ± 12 years. Twenty-eight patients (56%) had lone AF. Mean CHA2DS2-VASC and HAS-BLED scores were 3.1 ± 1.8 and 2.2 ± 1.2 respectively. Mean left ventricular ejection fraction was 44 ± 14% and left atrial surface was 28 ± 5 cm2. Fourteen patients (28%) were also taking antiplatelet therapy. Patients on rivaroxaban tended to have higher CHA2DS2-VASC scores than patients on dabigatran (3.6 ± 1.9 vs 2.6 ± 1.6, p=0.09), with a trend towards a greater history of stroke (23% vs 4%, p=0.10).

No clinical evidence of stroke occurred in the 30 days following cardioversion. One major gastrointestinal bleeding occurred (2%) in a patient on rivaroxaban, leading to transfusion of 3 units of blood and discontinuation of rivaroxaban. This patient was a 71 year-old male with liver cirrhosis and a glomerular filtration rate of 30 ml/min, taking 15mg rivaroxaban and 75mg aspirin therapy daily. Three minor bleedings occurred (6%), including 2 gastrointestinal bleedings in patients on dabigatran and one epistaxis in a patient on rivaroxaban. No other premature interruption of the anticoagulant was observed.

Our study adds to the growing body of evidence that the use of NOACs for cardioversion of AF is safe. Post-hoc analysis of major randomized trials3-5, a dedicated randomized trial [6], and several single-center observational studies7-9 have shown that the rates of thromboembolism following cardioversion were low and comparable to those with warfarin. The latest scientific guidelines2 now indicate that anticoagulation with any of the NOACs is reasonable in the peri-cardioversion period. The question remains as to which patients should undergo TEE prior to cardioversion. In recent observational studies, 20-24% of patients underwent TEE with no thrombus detected, and no thromboembolic events immediately after cardioversion in these TEE-cleared patients7-9. Coleman et al7 found that higher CHADS2/CHA2DS2-VASC scores were associated with thromboembolic risk but in our study one patient with thrombus had a score of 0, suggesting that TEE might be reasonable even in supposedly low-risk patients.

Table 1:

Patients with intra-atrial thrombus on transesophageal echocardiography

Patient Age/Sex Drug CHA2DS2 VASC Stroke history Aspirin LV ejection fraction (%) LA area (cm2)
1 42/M Dabigatran 110 mg 2 No No 26 36
2 57/M Rivaroxaban 20 mg 0 No 75mg 30 30

Abbreviations: LA: left atrium; LV: left ventricle.

Statement of ethical publishing

The authors agree to abide by the requirements of the « Statement of publishing ethics of the International Cardiovasular Forum Journal »10.

Conflict of interest:

There is no conflict of interest for any of the authors.



Camm AJ, Lip GY, De Caterina R, et al 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33: 2719–47


January CT, Wann LS, Alpert JS, et al 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130: e199–267 10.1161/CIR.0000000000000041


Nagarakanti R, Ezekowitz MD, Oldgren J, et al Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion. Circulation 2011; 123: 131–6 10.1161/CIRCULATIONAHA.110.977546


Piccini JP, Stevens SR, Lokhnygina Y, et al Outcomes after cardioversion and atrial fibrillation ablation in patients treated with rivaroxaban and warfarin in the ROCKET AF trial. J Am Coll Cardiol 2013; 61: 1998–2006 10.1016/j.jacc.2013.02.025


Flaker G, Lopes RD, Al-Khatib SM, et al Efficacy and safety of apixaban in patients after cardioversion for atrial fibrillation: insights from the ARISTOTLE Trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation). J Am Coll Cardiol 2014; 63: 1082–7 10.1016/j.jacc.2013.09.062


Cappato R, Ezekowitz MD, Klein AL, et al Rivaroxaban vs, vitamin K antagonists for cardioversion in atrial fibrillation. Eur Heart J 2014; 35: 3346–55 10.1093/eurheartj/ehu367


Coleman CM, Khalaf S, Mould S, et al Novel Oral Anticoagulants for DC Cardioversion Procedures: Utilization and Clinical Outcomes Compared with Warfarin. Pacing Clin Electrophysiol 2015; 38: 731–7 10.1111/pace.12618


Yadlapati A, Groh C, Passman R, Safety of short-term use of dabigatran or rivaroxaban for direct-current cardioversion in patients with atrial fibrillation and atrial flutter. Am J Cardiol 2014; 113: 1362–3 10.1016/j.amjcard.2013.12.044


Kochhäuser S, Khaykin Y, Beardsall J, et al Comparison of outcomes after cardioversion or atrial fibrillation ablation in patients with differing periprocedural anticoagulation regimens. Can J Cardiol 2014; 30: 1541–6 10.1016/j.cjca.2014.09.018


Shewan LG, Coats AJS, Henein M, Requirements for ethical publishing in biomedical journals. International Cardiovascular Forum Journal 2015; 2: 2 10.17987/icfj.v2i1.4

Copyright (c) 2015 COQUARD Charlène, MOUBARAK Ghassan, BAUDET Mathilde, LOGEART Damien, DILLINGER Jean-Guillaume, COHEN-SOLAL Alain

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