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Original research
Patterns of oral anticoagulation use with cardioversion in clinical practice
  1. Kyle Geurink1,
  2. DaJuanicia Holmes2,
  3. Michael D Ezekowitz3,
  4. Karen Pieper2,
  5. Gregg Fonarow4,
  6. Peter R Kowey5,
  7. James A Reiffel6,
  8. Daniel E Singer7,
  9. James Freeman8,
  10. Bernard J Gersh9,
  11. Kenneth W Mahaffey10,
  12. Elaine M Hylek11,
  13. Gerald Naccarelli12,
  14. Jonathan P Piccini2,13,
  15. Eric D Peterson2,14,
  16. Sean D Pokorney2,13
  1. 1 Duke University Health System, Durham, North Carolina, USA
  2. 2 Duke Clinical Research Institute, Durham, North Carolina, USA
  3. 3 Main Line Health, Bryn Mawr, PA, USA
  4. 4 Division of Cardiology, UCLA, Los Angeles, CA, USA
  5. 5 Cardiovascular Medicine, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
  6. 6 Cardiovascular Medicine, College of Physicians and Surgeons-Columbia University, New York, New York, USA
  7. 7 Harvard Medical School, Boston, MA, USA
  8. 8 Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
  9. 9 Mayo Clinic, Rochester, Minnesota, USA
  10. 10 Department of Medicine, Stanford Hospital and Clinics, Stanford, California, USA
  11. 11 Cardiovascular Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
  12. 12 Penn State Hershey Heart and Vascular Institute, Hershey, Pennsylvania, USA
  13. 13 Duke University School of Medicine, Durham, North Carolina, USA
  14. 14 Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
  1. Correspondence to Dr Kyle Geurink, Duke University Health System, Durham, NC 27710, USA; kylegeurink{at}


Background Cardioversion is common among patients with atrial fibrillation (AF). We hypothesised that novel oral anticoagulants (NOAC) used in clinical practice resulted in similar rates of stroke compared with vitamin K antagonists (VKA) for cardioversion.

Methods Using the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II, patients with AF who had a cardioversion, follow-up data and an AF diagnosis within 6 months of enrolment were identified retrospectively. Clinical outcomes were compared for patients receiving a NOAC or VKA for 1 year following cardioversion.

Results Among 13 004 patients with AF, 2260 (17%) underwent cardioversion. 1613 met the inclusion criteria for this analysis. At the time of cardioversion, 283 (17.5%) were receiving a VKA and 1330 (82.5%) a NOAC. A transoesophageal echocardiogram (TOE) was performed in 403 (25%) cardioversions. The incidence of stroke/transient ischaemic attack (TIA) at 30 days was the same for patients having (3.04 per 100 patient-years) or not having (3.04 per 100 patient-years) a TOE (p=0.99). There were no differences in the incidence of death (HR 1.19, 95% CI 0.62 to 2.28, p=0.61), cardiovascular hospitalisation (HR 1.02, 95% CI 0.76 to 1.35, p=0.91), stroke/TIA (HR 1.18, 95% CI 0.30 to 4.74, p=0.81) or bleeding-related hospitalisation (HR 1.29, 95% CI 0.66 to 2.52, p=0.45) at 1 year for patients treated with either a NOAC or VKA.

Conclusions Cardioversion was a low-risk procedure for patients treated with NOAC, and there were statistically similar rates of stroke/TIA 30 days after cardioversion as for patients treated with VKA. There were no statically significant differences in death, stroke/TIA or major bleeding at 1 year among patients treated with NOAC compared with VKA after cardioversion.

  • atrial fibrillation
  • electrocardiography

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  • Contributors MDE, GF, PRK, JAR, DES, JF, BJG, KWM, EMH, GN, JPP, EDP and SDP were involved in the planning of the ORBIT-AF II registry noted in our manuscript. All personally reviewed the manuscript and were involved in its creation. DH and KP led the statistical analyses and assisted with planning of the study itself. The manuscript was authored by SDP and KG with contributions from all stated authors. SDP and KG are guarantors of this work.

  • Funding The ORBIT-AF II registry is sponsored by Janssen Scientific Affairs, Raritan, NJ.

  • Competing interests BJG: member of a Data Safety Monitoring Board for Mount Sinai St Luke's, Boston Scientific, Teva Pharmaceutical Industries, St Jude Medical, Janssen Research & Development, Baxter Healthcare and Cardiovascular Research Foundation; consultant/Advisory Board for Janssen Scientific Affairs, Cipla, Armetheon and Medtronic. MDE: consultant/Advisory Board and grant support from Boehringer Ingelheim, Diachi Sanko, Pfizer, Bristol Myers Squibb and Janssen Scientific Affairs. PRK: consultant for Johnson and Johnson. JAR: research grant from Janssen Pharmaceuticals; research support from Boehringer Ingelheim Pharmaceuticals and GlaxoSmithKline; consultancies with Sanofi, Gilead Sciences, CV Therapeutics, GlaxoSmithKline, Merck & Co, Cardiome Pharma, Boehringer Ingelheim Pharmaceuticals and Medtronic; speakers bureau income from Sanofi and Boehringer Ingelheim Pharmaceuticals. GN: research grant from Janssen; consultant/Advisory Board for Janssen and Daiichi Sankyo. KWM: financial disclosures can be viewed at DES: consultant/Advisory Board for Boehringer Ingelheim, Bristol Myers Squibb, Merck, Johnson and Johnson, Pfizer and Medtronic; research grants from Boehringer Ingelheim and Bristol Myers Squibb. JF: consultant/Advisory Board for Janssen Scientific.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the Duke University Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. Data are not available.