Trial results for anticoagulants for cardioversion in AF patients published

August 30, 2016

The results of the largest known clinical trial to investigate the use of anticoagulants prior and post cardioversion in atrial fibrillation patients, published in The Lancet, show that non-vitamin K antagonist oral anticoagulants (NOACs) could be equally as effective as the currently used warfarin.

The study found that edoxaban, a NOAC, could be used as a safe alternative to the traditionally used warfarin, and could expedite the process from initial standard treatment including enoxaparin/warfarin to elective cardioversion when applying a TEE-guided approach (transesophageal echocardiography).

The prospective, randomised clinical trial was carried out across multiple centres in 19 countries, and compared a 60 mg daily dose of edoxaban with the current treatment of enoxaparin-warfarin.

2199 patients due to undergo electrical cardioversion for non-valvular atrial fibrillation were recruited to the trial and randomly assigned to receive one of the two treatments.

Five of the 1067 who received edoxaban, and 11 of the 1082 who received enoxaparin-warfarin, experienced a stroke, systemic embolism, myocardial infarction, or significant event of a similar nature during the course of treatment.

Atrial fibrillation is the most common heart rhythm abnormality worldwide, affecting around approximately 33?5 million people worldwide(1), and if over 40 years of age, there is a 1 in 4 lifetime risk of developing this arrhythmia. Atrial fibrillation carries a substantial risk of stroke and death, and the incidence of this condition has continued to rise in recent years.

Atrial fibrillation is represented by an irregular heartbeat caused by abnormal electrical impulses in the atria. Restoring a regular heartbeat is often attempted through the use of electrical cardioversion, antiarrhythmic drugs, or a combination of both.

Current guidelines recommend a minimum of three weeks of therapeutic anticoagulation prior to the cardioversion in order to reduce the risk of thromboembolism (ie. blood clotting) which can lead to stroke events. This time may be shortened when imaging techniques (such as transesophageal echocardiography) are used to visualise presence of thrombi in the atria. Strokes related to atrial fibrillation are more likely to be fatal or disabling compared to non-atrial fibrillation related strokes.

Stroke prevention in atrial fibrillation is typically done via Vitamin K antagonists, such as warfarin, but these come with limitations. There are significant variabilities on how warfarin works for individual patients, and as such requires regular monitoring and adjustment, which can cause delays before cardioversion may commence.

While there have been previous smaller studies, the NOACs have not been investigated on a large scale as with the ENSURE-AF trial, and have not been compared against the optimised standard of care for warfarin.

Dr. Gregory Lip, Professor of Cardiovascular Medicine from the University of Birmingham, explained, "The purpose of this trial was to optimise care for patients undergoing restorative treatment for atrial fibrillation. Both the optimised use of warfarin, and in this case edoxaban, displayed very low numbers of events and can be considered as safe. What we present here is the option for using NOACs such as edoxaban as a more efficient, user-friendly choice before cardioversion. But before that comes into place, it needs the support of revised guidelines and supporting education for healthcare practitioners and patients alike."
The study was financially supported by Daiichi Sankyo. Professor Gregory Lip and Professor Andreas Goette (University Hospital Magdeburg, Germany) chaired the research group.

University of Birmingham

Related Stroke Articles from Brightsurf:

Stroke alarm clock may streamline and accelerate time-sensitive acute stroke care
An interactive, digital alarm clock may speed emergency stroke care, starting at hospital arrival and through each step of the time-sensitive treatment process.

Stroke patients with COVID-19 have increased inflammation, stroke severity and death
Stroke patients who also have COVID-19 showed increased systemic inflammation, a more serious stroke severity and a much higher rate of death, compared to stroke patients who did not have COVID-19, according a retrospective, observational, cross-sectional study of 60 ischemic stroke patients admitted to UAB Hospital between late March and early May 2020.

'Time is vision' after a stroke
University of Rochester researchers studied stroke patients who experienced vision loss and found that the patients retained some visual abilities immediately after the stroke but these abilities diminished gradually and eventually disappeared permanently after approximately six months.

More stroke awareness, better eating habits may help reduce stroke risk for young adult African-Americans
Young African-Americans are experiencing higher rates of stroke because of health conditions such as high blood pressure, diabetes and obesity, yet their perception of their stroke risk is low.

How to help patients recover after a stroke
The existing approach to brain stimulation for rehabilitation after a stroke does not take into account the diversity of lesions and the individual characteristics of patients' brains.

Kids with headache after stroke might be at risk for another stroke
A new study has found a high incidence of headaches in pediatric stroke survivors and identified a possible association between post-stroke headache and stroke recurrence.

High stroke impact in low- and middle-income countries examined at 11th World Stroke Congress
Less wealthy countries struggle to meet greater need with far fewer resources.

Marijuana use might lead to higher risk of stroke, World Stroke Congress to be told
A five-year study of hospital statistics from the United States shows that the incidence of stroke has risen steadily among marijuana users even though the overall rate of stroke remained constant over the same period.

We need to talk about sexuality after stroke
Stroke survivors and their partners are not adequately supported to deal with changes to their relationships, self-identity, gender roles and intimacy following stroke, according to new research from the University of Sydney.

Standardized stroke protocol can ensure ELVO stroke patients are treated within 60 minutes
A new study shows that developing a standardized stroke protocol of having neurointerventional teams meet suspected emergent large vessel occlusion (ELVO) stroke patients upon their arrival at the hospital achieves a median door-to-recanalization time of less than 60 minutes.

Read More: Stroke News and Stroke Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to