DOACs in elective electrical cardioversion 21 1. Introduction Direct oral anticoagulants (DOACs) are currently the preferred choice of oral anticoagulation in patients with atrial fibrillation (AF) for long-term stroke prevention (1). Electrical cardioversion (ECV) play an important role in a rhythm control strategy, therefore it is not surprising that many patients undergoing ECV are treated with a DOAC. For patients with AF of >48 hours duration, it is recommended to use therapeutic oral anticoagulation at least 3 weeks before and 4 weeks after ECV (2). An advantage of DOAC is that therapeutic oral anticoagulation can be achieved rapidly, which is especially relevant for anticoagulation naïve patients. However, it is important to ensure adherence to the DOAC intake, as there is no coagulation assay available providing information on effective anticoagulation over the past 3 weeks. Post-hoc subgroup analysis from large phase 3 stroke prevention trials have shown a good safety profile of DOACs pericardioversion with a thromboembolic risk of <1% (3-6). Furthermore, prospective randomized controlled trials (RCTs) in patients requiring elective ECV demonstrated low and similar thromboembolic and bleeding rates when comparing factor Xa inhibitors to vitamin K antagonists (VKA) (7-9). It is important to note that all RCTs were not powered to demonstrate noninferiority. In addition, the majority (>50%) of patients in the RCTs underwent transoesophageal echocardiography (TEE) to guide cardioversion, which is not routine practice in many centers. There is limited real-world data of DOACs in patients undergoing elective ECV outside the scope of highly controlled RCT (10-18). The availability of real-world data is important as it reflects actual clinical practice. For example, in many centers it is not common practice to have a preprocedural TEE before an elective ECV. We evaluated the efficacy and safety of DOACs versus VKA in patients undergoing elective ECV for atrial tachyarrhythmia in a large tertiary referral center without routine preprocedural TEE. 2
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