A. Direct current cardioversion with aspirin alone for thromboembolism prophylaxis

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7. A. Direct current cardioversion with aspirin alone for thromboembolism prophylaxis

When the duration of atrial fibrillation is thought to be less than 48 hours, transesophageal echocardiography is not required to evaluate for left atrial appendage thrombus. Direct current cardioversion can safely be performed with very low risk for thromboembolism in this situation.

The determination of anticoagulation after direct current cardioversion is based on an individual patient’s risk using the CHA₂DS₂-VASc score. This patient has a score of 0, and thus aspirin alone afterwards is considered adequate.

Another reasonable approach would be to simply rate-control the atrial fibrillation with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) and/or beta-blockers, then reevaluate symptoms. Direct current cardioversion could be performed at a later time; however, once the duration is beyond 48 hours, full anticoagulation needs to be initiated 3 to 4 weeks before and after the procedure regardless of the thromboembolic risk (CHA₂DS₂-VASc score).

8. B. Direct current cardioversion with full anticoagulation for 3 to 4 weeks afterwards for thromboembolism prophylaxis

When the duration of atrial fibrillation is thought to be less than 48 hours, transesophageal echocardiography is not required to evaluate for left atrial appendage thrombus. Direct current cardioversion can safely be performed with very low risk of thromboembolism in this situation.

The determination of anticoagulation after direct current cardioversion, when the duration of the atrial fibrillation is less than 48 hours, is based on the individual patient’s risk using the CHA₂DS₂-VASc score. This patient has a score of 3, and thus full anticoagulation afterwards (warfarin, dabigatran, rivaroxaban) is required.

Another reasonable approach would be to simply rate-control the atrial fibrillation with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) and/or beta-blockers, then reevaluate symptoms. Direct current cardioversion could be performed at a later time; however, once the duration is beyond 48 hours, full anticoagulation needs to be initiated 3 to 4 weeks before and after the procedure regardless of the thromboembolic risk (CHA₂DS₂-VASc score).

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