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Abstract
Background Atrial fibrillation is the most common sustained arrhythmia worldwide. Patients are at increased risk of death, heart failure, hospitalisation and stroke. Elective DCCV is widely used to restore sinus rhythm to improve symptoms and prevent adverse cardiac remodelling. National guidelines recommend anticoagulation (AC) at least 3 weeks prior to DCCV followed by 4 weeks of AC. Following this, the need for long term AC should be assessed. Previous local audit has highlighted that one third of DCCV cancellations were due to AC issues. In 2013, we began to use DOAC for planned DCCV.
Purpose To compare the DCCV cancellation rate between patients who were on Warfarin and those who were on DOACs in 2016.
Methods All cancellations were identified from retrospective analysis of data of elective DCCVs performed in this local health board in 2016.
Results In 2016, there were a total of 263 DCCV requests received. 153 (59%) patients were on warfarin, 108 (40%) on a DOAC and one was on tinzaparin. There were 59 cancellations in total. Forty seven (80%) of these were of patients on warfarin. Almost 81% (n=38) of the these were postponed due to low INR, 9 were found to be in sinus rhythm, 2 were acutely ill due to unrelated medical issues, one patient refused the procedure and 4 were cancelled due to unknown reasons. In the DOAC group, 2 had poor compliance with the medication so DCCV was delayed, 5 were in sinus rhythm at pre assessment and 4 patients were cancelled due to miscellaneous reasons namely patient refusal, on-going infections or due to medical admission. DOACs were as follows: Rivaroxiban (37.9%), Apixaban (38.8%) and Dabigatran (22.2%).
When waiting time was compared between the two groups, the warfarin group had an average waiting time of 101 days from the time of referral to the day of DCCV whereas the DOAC group had an average waiting time of 74 days.
We also compared these results with a local audit performed in 2013 where 136 (100%) of the patients were on warfarin, of which 40 (29%) were cancelled. Of these 24 (60%) had suboptimal anticoagulation leading to poor INR control. In addition, 6 patients were cancelled as they were in sinus rhythm before DCCV, 3 refused and 4 had medical reasons.
Conclusions Warfarin remains the most commonly prescribed drug in atrial fibrillation and was responsible for the bulk of cancellations and delays in cardioversions.
Using a DOAC instead of warfarin for elective DCCV resulted in an overall reduction in the number of procedural cancellations.
The use of a DOAC reduced the waiting time for DCCV and this potentially could reduce adverse cardiac remodelling.
Where DCCV is planned a DOAC should now be the preferred choice rather than warfarin for patients with non-valvular AF.
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