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Thromboembolism prevention in patients with atrial fibrillation or atrial flutter: recommendations


For patients with atrial fibrillation or atrial flutter of 48-hour duration or longer, or when the duration of atrial fibrillation is unknown, anticoagulation with Warfarin ( INR 2.0 to 3.0 ) is recommended for at least 3 weeks prior to and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and the method ( electrical or pharmacological ) used to restore sinus rhythm. ( Class I; Level of Evidence: B )

For patients with atrial fibrillation or atrial flutter of more than 48 hours or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated. ( Class I; Level of Evidence: C )

For patients with atrial fibrillation or atrial flutter of less than 48-hour duration and with high risk of stroke, intravenous Heparin or low-molecular-weight heparin ( LMWH ), or administration of a factor Xa or direct thrombin inhibitor, is recommended as soon as possible before or immediately after cardioversion, followed by longterm anticoagulation therapy. ( Class I; Level of Evidence: C )

Following cardioversion for atrial fibrillation of any duration, the decision regarding long-term anticoagulation therapy should be based on the thromboembolic risk profile. ( Class I; Level of Evidence: C )

For patients with atrial fibrillation or atrial flutter of 48-hour duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform a TEE ( transesophageal echocar-diography ) prior to cardioversion and proceed with cardioversion if no left atrial ( LA ) thrombus is identified, including in the left atrial appendage ( LAA ), provided that anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks. ( Class IIa; Level of Evidence: B )

For patients with atrial fibrillation or atrial flutter of 48-hour duration or longer, or when the duration of atrial fibrillation is unknown, anticoagulation with Dabigatran, Rivaroxaban, or Apixaban is reasonable for at least 3 weeks prior to and 4 weeks after cardioversion. ( Class IIa; Level of Evidence: C )

For patients with atrial fibrillation or atrial flutter of less than 48-hour duration who are at low thromboembolic risk, anticoagulation ( intravenous Heparin, LMWH, or a new oral anticoagulant ) or no antithrombotic therapy may be considered for cardioversion, without the need for postcardioversion oral anticoagulation. ( Class IIb; Level of Evidence: C ) ( Xagena )

Source: AHA/ACC/HRS Atrial Fibrillation Guideline 2014

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