Role of Anticoagulation in valvular atrial fibrillation with hemodynamic instability
55 year old female with shortness of breath and pedal edema since 5 days
Discussion -
: Pt has high risk of thromboembolism is -
Valvular AF .
Was she on warfarin before ?
Should we start her on anticoagulation ?
.This patient is having Mitral stenosis ,so AF might be chronic , ideally she should be given anticoagulation 3 weeks before and 4 weeks after cardioversion .
we need cofirm if there is any clot with trans esophageal echo and then go with cardioversion .
: But as patient is unstable ,we can go with cardioversion ?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861334/: None of the identified studies dealt with the issue of anticoagulation in patients with acute haemodynamically unstable atrial fibrillation. It is known that the onset of atrial fibrillation is associated with a cluster of thromboembolic events,8 but the development of intra‐atrial thrombi and hence the immediate risk of thromboembolism is regarded as very small (but not insignificant) in the first 48 h. A study of 357 patients with symptoms indicating the onset of acute atrial fibrillation showed that thromboembolism occured in three patients in whom sinus rhythm was restored within 48 h (250 reverted spontaneously and 107 underwent cardioversion; none were anticoagulated);9 indeed, similar rates of thromboembolism have been found in other studies.10 However, intra‐atrial thrombus has been detected by transoesophageal echocardiography in 15% of patients with atrial fibrillation of <72 h duration
There have been no studies on patients with acute‐onset atrial fibrillation directly comparing the risk of thromboembolism with the risks of anticoagulation. Thus, it was recommended that heparin (either unfractionated or low molecular weight) be used as soon as possible. If, however, the patient was in extremis, no intervention should delay the treatment directed specifically at reverting or controlling the atrial fibrillation
2-https://www.jacc.org/doi/abs/10.1016/S0735-1097(02)02052-1
If we consider long standing AF - without any prior anticoagulation (warfarin )
133 under went DCC
Out of which 2 patients had emboli .
Risk of embolism is decreased when INR was more than 2.5
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