A short cut review was carried out to establish whether anticoagulation is indicated after emergency department cardioversion of a patient with acute onset atrial fibrillation. 243 papers were found using the reported search, of which none presented any evidence to answer the clinical question. It is concluded that there is no evidence available to answer this question. Further research is needed.
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Report by Katherine Potier, Specialist Registrar, Emergency Medicine Checked by Richard Parris, Locum ED Consultant
A 45 year old man who presented to your emergency department with new onset AF has been successfully chemically cardioverted. You wonder whether he needs anti-coagulating on discharge to prevent any longer term thromboembolic complications.
Three part question
In a [patient with acute atrial fibrillation who has cardioverted to sinus rhythm] does [anticoagulation post-cardioversion] [reduce the incidence of thromboembolic complications]?
Medline 1966-12/04 using the OVID interface and The Cochrane Library, Issue 4, 2004. Medline: [exp Atrial fibrillation OR AF.mp OR atrial fibrillation.mp] AND [exp electric countershock OR cardioversion.mp OR exp anti arrhythmia agents OR chemical cardioversion.mp] AND [exp heparin OR heparin.mp OR exp heparin, low molecular weight OR low molecular weight heparin.mp OR fractionated heparin.mp OR bemiparin.mp OR certoparin.mp OR dalteparin.mp OR oxaparin.mp OR reviparin.mp OR tinzaparin.mp OR fragmin.mp OR clexane.mp OR exp warfarin or warfarin.mp OR exp coumarins OR coumarins.mp OR exp aspirin OR aspirin.mp] LIMIT to human AND English language.
Cochrane: (atrial fibrillation) AND (anticoagulation) AND (cardioversion)
A total of 243 papers were found, none of which answered the three part question.
No relevant papers given.
It has been recommended that patients with AF lasting more than 2 days should be anticoagulated for at least 1 month post cardioversion. This is because of the formation of intratrial thrombus and the potential for embolic events with atrial stunning. However, there is no evidence to support this approach in AF of shorter duration as the likelihood of cardioversion related thromboembolism is thought to be very low.
CLINICAL BOTTOM LINE
There is no evidence to support the anticoagulation of patients with new onset AF on discharge, who have been successfully cardioverted in the emergency department (whether this be chemically, electrically, or spontaneously).