13th International Congress
THE "NEW FRONTIERS"
OF ARRHYTHMIAS 1998

January 24-31, 1998
Marilleva, Trento, Italy

RT-142

Electric cardioversion of atrial fibrillation: anticoagulant prophylaxis with calcic and sodic heparin and dicoumarolics

Mauro Giuliani, Ruggero Cabri, Francesco Marzani, Mariano Capitelli, Roberto Salati.
Unita Operativa di Medicina Interna, Modulo di Cardiologia, Ospedale di Pavullo, Modena, Italy

Background

Atrial fibrillation is the most common arrhythmia among the adult population and more than 15% of all cerebral strokes are associated with this arrhythmia. Thus, in order to reduce serious thromboembolic risk, and to restore the hemodynamic advantages, there is unanimous agreement in attempting to restore sinus rhythm, wherever possible. However, both the electric and the pharmacological cardioversion can involve significant embolic risk (1.55; 0-9%)¹.

According to retrospective and non-randomized clinical studies², anticoagulation treatment can significantly reduce the embolic risk associated with cardioversion by as much as 0 to 1.6%. On the basis of these findings and in accordance with the recommendations of the American College of Chest Physicians, anticoagulant treatment is generally adopted in the³ weeks preceding and the 4 weeks following the cardioversion procedure for patients with atrial fibrillation of a duration exceeding 48 hours 3. However, traditional anticoagulant treatment with dicumarol administered orally reduces the embolic risk, without eliminating it entirely, while also introducing a variety of disadvantages as the risk of hemorrhaging from anticoagulants⁴ and careful laboratory monitoring involving a high degree of patient cooperation and increased costs. Moreover, most importantly, along with the possible reduction in the effectiveness of the cardioversion procedure, there is also an increased probability of recurring arrhythmia and of the post-cardioversion thromboembolic risk⁵. From here the attempts to reduce the time periods needed for the pre-cardioversion anticoagulation process through the use of transesophageal echocardiography for the exclusion of intracavitary thrombi. The studies conducted by Manning and co-workers⁶ on the use of transesophageal echocardiography in guiding cardioversion from atrial fibrillation represent an essential effort in this regard. At present, even if the situation is extremely controversial, other researchers have also proposed rapid anticoagulant treatment protocols with heparin administered intravenously by drip treatment for 24-48 hours after having excluded the presence of thrombi by echocardiography^7,8.