Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://www.cardiologyres.org

Original Article

Volume 13, Number 2, April 2022, pages 88-96

Trends and Outcomes of Oral Anticoagulation With Direct Current Cardioversion for Atrial Fibrillation/Flutter at an Academic Medical Center

Figure 2. Trends in the use of oral anticoagulation from 2015 to 2020 in patients undergoing direct current cardioversion. (a) Use of anticoagulants for 30 days or more prior to cardioversion. (b) Anticoagulation use at the time of cardioversion. (c) Anticoagulation on discharge after cardioversion.

Figure 3. Declining intravenous/subcutaneous anticoagulation during cardioversion with rise of DOACs over 2015 - 2020. DOACs: direct oral anticoagulants.

**Table 1.** Baseline Characteristics of Patients
Baseline patient characteristics	N = 515
LVAD: left ventricular assist device; LVEF: left ventricular ejection fraction; TIA: transient ischemic attack.
Males	351 (68%)
Diabetes mellitus	146 (28%)
Hypertension	311 (60%)
Coronary artery disease	153 (30%)
Hyperlipidemia	172 (33%)
Chronic kidney disease	47 (9%)
End-stage renal disease	11 (2%)
Renal transplant	6 (1%)
Heart failure	266 (52%)
LVAD	8 (1%)
Heart transplant	2 (< 1%)
Liver cirrhosis	9 (2%)
Body mass index	32 (16 - 78)
Congestive heart failure	266 (52%)
LVEF < 40%	171 (33%)
CHA₂DS₂VASc	2.6 ± 1.6
0	40 (8%)
1	89 (17%)
2	123 (24%)
3	94 (18%)
4	78 (15%)
5	48 (9%)
6	16 (3%)
7	4 (< 1%)
8	3 (< 1%)
Prior stroke/TIA	38 (7%)
Prior major bleeding	25 (5%)
Prior venous thromboembolism	64 (12%)
Prior cardioversion	140 (27%)
Prior ablation	42 (8%)

Table 1. Baseline Characteristics of Patients

Baseline patient characteristics

N = 515

LVAD: left ventricular assist device; LVEF: left ventricular ejection fraction; TIA: transient ischemic attack.

Males

351 (68%)

Diabetes mellitus

146 (28%)

Hypertension

311 (60%)

Coronary artery disease

153 (30%)

Hyperlipidemia

172 (33%)

Chronic kidney disease

47 (9%)

End-stage renal disease

11 (2%)

Renal transplant

6 (1%)

Heart failure

266 (52%)

LVAD

8 (1%)

Heart transplant

2 (< 1%)

Liver cirrhosis

9 (2%)

Body mass index

32 (16 - 78)

Congestive heart failure

266 (52%)

LVEF < 40%

171 (33%)

CHA₂DS₂VASc

2.6 ± 1.6

40 (8%)

89 (17%)

123 (24%)

94 (18%)

78 (15%)

48 (9%)

16 (3%)

4 (< 1%)

3 (< 1%)

Prior stroke/TIA

38 (7%)

Prior major bleeding

25 (5%)

Prior venous thromboembolism

64 (12%)

Prior cardioversion

140 (27%)

Prior ablation

42 (8%)

**Table 2.** Reasons for No Anticoagulation on Discharge After Cardioversion
Reason	N = 31
CABG: coronary artery bypass graft; LAA: left atrial appendage.
Cardioversion post CABG and anticoagulation deemed not necessary by surgeon	5
Recent surgery and anticoagulation deemed not safe	1
Significant thrombocytopenia (< 50,000)	2
Patient refusal	1
HAS-BLED score ≥ 3	1
Recent gastrointestinal bleeding	3
LAA occlusion device with prior history of major bleeding	3
Multi-organ dysfunction	4
Indiscernible	11

Table 2. Reasons for No Anticoagulation on Discharge After Cardioversion

Reason

N = 31

CABG: coronary artery bypass graft; LAA: left atrial appendage.

Cardioversion post CABG and anticoagulation deemed not necessary by surgeon

Recent surgery and anticoagulation deemed not safe

Significant thrombocytopenia (< 50,000)

Patient refusal

HAS-BLED score ≥ 3

Recent gastrointestinal bleeding

LAA occlusion device with prior history of major bleeding

Multi-organ dysfunction

Indiscernible

**Table 3.** Patient Demographics Based on Type of Post-Procedural Anticoagulation
Demographics	DOACs, n = 338 (65%)	Warfarin, n = 124 (24%)	P value
*P value < 0.05. EF: ejection fraction.
Age	62 ± 13.073	61 ± 13.5	0.721
CHA₂DS₂VASc	2.65 ± 1.6	2.9 ± 1.4	0.037*
Body mass index	32.1 ± 8.1	34.3 ± 11.1	0.017*
Male gender	235 (70%)	80 (65%)	0.306
Diabetes mellitus	91 (27%)	38 (31%)	0.429
Hypertension	202 (60%)	77 (62%)	0.65
Coronary artery disease	96 (28%)	43 (35%)	0.193
Hyperlipidemia	109 (32%)	49 (40%)	0.145
Chronic kidney disease stage 3 - 5	23 (7%)	20 (16%)	0.002*
End-stage renal disease	5 (1%)	5 (4%)	0.08
Congestive heart failure	172 (51%)	49 (40%)	0.09
Heart failure with reduced ejection fraction (EF < 40%)	106 (31%)	53 (43%)	0.023*
History of prior stroke	24 (7%)	12 (10%)	0.36
History of venous thromboembolism	34 (11%)	21 (17%)	0.043*
Prior history of major bleeding	7 (2%)	8 (6%)	0.019*
Concomitant aspirin use	78 (23%)	48 (39%)	0.001*
Concomitant clopidogrel use	8 (2%)	9 (7%)	0.013*
Triple antithrombotic therapy	1 (< 1%)	5 (4%)	0.002*
Transesophageal echocardiogram prior to cardioversion	140 (41%)	54 (44%)	0.681
Prior cardioversions	94 (28%)	36 (29%)	0.796
Atrial fibrillation	218 (65%)	71 (57%)	0.154
Atrial flutter	120 (36%)	53 (43%)	0.154
Anti-arrhythmic use prior to cardioversion	137 (41%)	53 (43%)	0.686

Table 3. Patient Demographics Based on Type of Post-Procedural Anticoagulation

Demographics

DOACs, n = 338 (65%)

Warfarin, n = 124 (24%)

P value

*P value < 0.05. EF: ejection fraction.

Age

62 ± 13.073

61 ± 13.5

0.721

CHA₂DS₂VASc

2.65 ± 1.6

2.9 ± 1.4

0.037*

Body mass index

32.1 ± 8.1

34.3 ± 11.1

0.017*

Male gender

235 (70%)

80 (65%)

0.306

Diabetes mellitus

91 (27%)

38 (31%)

0.429

Hypertension

202 (60%)

77 (62%)

0.65

Coronary artery disease

96 (28%)

43 (35%)

0.193

Hyperlipidemia

109 (32%)

49 (40%)

0.145

Chronic kidney disease stage 3 - 5

23 (7%)

20 (16%)

0.002*

End-stage renal disease

5 (1%)

5 (4%)

0.08

Congestive heart failure

172 (51%)

49 (40%)

0.09

Heart failure with reduced ejection fraction (EF < 40%)

106 (31%)

53 (43%)

0.023*

History of prior stroke

24 (7%)

12 (10%)

0.36

History of venous thromboembolism

34 (11%)

21 (17%)

0.043*

Prior history of major bleeding

7 (2%)

8 (6%)

0.019*

Concomitant aspirin use

78 (23%)

48 (39%)

0.001*

Concomitant clopidogrel use

8 (2%)

9 (7%)

0.013*

Triple antithrombotic therapy

1 (< 1%)

5 (4%)

0.002*

Transesophageal echocardiogram prior to cardioversion

140 (41%)

54 (44%)

0.681

Prior cardioversions

94 (28%)

36 (29%)

0.796

Atrial fibrillation

218 (65%)

71 (57%)

0.154

Atrial flutter

120 (36%)

53 (43%)

0.154

Anti-arrhythmic use prior to cardioversion

137 (41%)

53 (43%)

0.686

**Table 4.** Characteristics of Patients With Stroke After Direct Current Cardioversion
Age	Gender	CHA₂DS₂VASc	TEE	Anticoagulation	Comments
TEE: transesophageal echocardiography.
53	Male	0	Not performed	Warfarin	Preceding surgery for ischemic bowel
57	Female	2	Not performed	Rivaroxaban	Seizure
64	Male	3	Not performed	None	Preceding liver transplant surgery
61	Female	4	Not performed	None	Recent gastrointestinal bleed

Table 4. Characteristics of Patients With Stroke After Direct Current Cardioversion

Age

Gender

CHA₂DS₂VASc

TEE

Anticoagulation

Comments

TEE: transesophageal echocardiography.

Male

Not performed

Warfarin

Preceding surgery for ischemic bowel

Female

Not performed

Rivaroxaban

Seizure

Male

Not performed

None

Preceding liver transplant surgery

Female

Not performed

None

Recent gastrointestinal bleed