Is transesophageal echocardiography necessary before electrical cardioversion in patients treated with non-vitamin K antagonist oral anticoagulants? Current evidence and practical approach.

According to current guidelines, non-vitamin K antagonist oral anticoagulants (NOACs) should be used at least 3 weeks before planned electrical cardioversion. In accordance with international atrial fibrillation (AF) guidelines, transesophageal echocardiography (TEE) is a pre-procedural examination recommended as an alternative to adequate oral anticoagulation. The strategy related to qualifying patients treated with NOACs for pre-procedural TEE differs in individual centers. Therefore, it is necessary to create an algorithm that will standardize estimation of left atrial appendage thrombus (LAAT) prevalence risk and thereby qualify NOAC-treated patients to TEE in the most effective way. We assessed the available studies on LAAT predictors. Risk factors for LAAT formation are not necessarily the same as the risk factors for thromboembolic events in patients with AF. The main risk factor for LAAT are as follows: previous intracardiac thrombus, irregular use of NOAC, inappropriate dose reduction of NOAC, previous stroke, CHA2DS2-VASc score ≥ 3 points, glomerular filtration rate < 60 mL/min/1.73 m², reduced left ventricular ejection fraction, or left atrial enlargement. Based on available evidence, we proposed algorithm guarantees more systematic approach to performing TEE in patients undergoing electrical cardioversion.

Temporal Trends in Oral Anticoagulant Prescription in Atrial Fibrillation Patients between 2004 and 2019.

BACKGROUND: In the recent years, antithrombotic prophylaxis in patients with atrial fibrillation (AF) has changed significantly. The main aim of this study is to assess the temporal trends of antithrombotic therapy and identify factors predisposing oral anticoagulant (OAC) use in stroke prevention in AF patients. METHODS: The present study is a retrospective, observational, single-center study, which includes consecutively hospitalized patients in the reference cardiology center from January 2004 to December 2019. RESULTS: A total of 9656 patients (43.7% female, mean age 71.2 years) with AF between 2004-2019 are included. Among the total study population, in most of the patients (81.1%), OAC therapy was used, antiplatelet (APT) therapy was prescribed for 13.5% patients, heparins for 2.1% patients and 3.3% of patients did not receive any stroke prevention. OAC prescription significantly increased from 61.6% in 2004 to 97.4% in 2019. The independent predictors of OAC prescription were: the period of hospitalization, non-paroxysmal AF, age, hypertension, diabetes mellitus, previous thromboembolism, hospitalization due to electrical cardioversion, ablation or AF without any procedures. CONCLUSIONS: In hospitalized patients with AF, during sixteen years of the study period, a significant increase in OAC use and a decrease in APT use were noted. Factors other than these included in the CHA2DS2-VASc score were independent predictors of OAC use.