Thromboembolic and bleeding complications after elective cardioversion of atrial fibrillation: a nationwide cohort study

Author:

Itäinen-Strömberg Saga1ORCID,Lehto Mika23ORCID,Halminen Olli4ORCID,Putaala Jukka5ORCID,Haukka Jari6ORCID,Lehtonen Ossi7ORCID,Teppo Konsta8ORCID,Mustonen Pirjo8ORCID,Linna Miika47ORCID,Hartikainen Juha79ORCID,Airaksinen Kari Eino Juhani8ORCID,Aro Aapo L1ORCID

Affiliation:

1. Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland

2. Jorvi Hospital, Department of Internal Medicine, HUS Helsinki University Hospital, Espoo, Finland

3. University of Helsinki, Faculty of Medicine , Helsinki , Finland

4. Aalto University , Department of Industrial Engineering and Management, Espoo , Finland

5. Department of Neurology, Helsinki University Hospital, Helsinki, Finland

6. Faculty of Medicine, University of Helsinki , Clinicum, Finland

7. University of Eastern Finland , School of Medicine, Kuopio , Finland

8. Heart Center, Turku University Hospital and University of Turku, Turku, Finland

9. Heart Center, Kuopio University Hospital , Kuopio , Finland

Abstract

Abstract Aims Elective cardioversion (ECV) is routinely used in atrial fibrillation (AF) to restore sinus rhythm. However, it includes a risk of thromboembolism even during adequate oral anticoagulation treatment. The aim of this study was to evaluate the risk of thromboembolic and bleeding complications after ECV in a real-life setting utilizing data from a large AF population. Methods and results This nationwide register-based study included all (n = 9625) Finnish AF patients undergoing their first-ever ECV between 2012 and 2018. The thromboembolic and bleeding complications within 30 days after ECV were analysed. The mean age of the patients was 67.7 ± 9.9 years, 61.2% were men, and the mean CHA2DS2-VASc score was 2.6 ± 1.6. Warfarin was used in 6245 (64.9%) and non-vitamin K oral anticoagulants (NOACs) in 3380 (35.1%) cardioversions. Fifty-two (0.5%) thromboembolic complications occurred, of which 62% were ischaemic strokes, 25% transient ischaemic attacks, and 13% other systemic embolisms. Thromboembolic events occurred in 14 (0.4%) NOAC-treated patients and in 38 (0.6%) warfarin-treated patients (odds ratio 0.77; confidence interval: 0.42–1.39). The median time from ECV to the thromboembolic event was 2 days, and 78% of the events occurred within 10 days. Age and alcohol abuse were significant predictors of thromboembolic events. Among warfarin users, thromboembolic complications were more common with international normalized ratio (INR) <2.5 than INR ≥2.5 (0.9% vs. 0.4%, P = 0.026). Overall, 27 (0.3%) bleeding events occurred. Conclusion The rate of thromboembolic and bleeding complications related to ECV was low without significant difference between NOAC- and warfarin-treated patients. With warfarin, INR ≥2.5 at the time of cardioversion reduced the risk of thromboembolic complications.

Funder

Helsinki and Uusimaa Hospital District

Finnish Foundation for Cardiovascular Research

Aarne Koskelo Foundation

Yrjö Jahnsson Foundation

Sigrid Juselius Foundation

Einar och Karin Stroems Foundation

Otto A. Malmin Foundation

Academy of Finland

Bayer

Publisher

Oxford University Press (OUP)

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