Skip to main content
SpringerLink
Log in

Low molecular weight heparin (parnaparin) for cardioembolic events prevention in patients with atrial fibrillation undergoing elective electrical cardioversion: a prospective cohort study

  • IM - Original
  • Published:
Internal and Emergency Medicine Aims and scope Submit manuscript

Abstract

Systemic thromboembolism is a severe complication in patients undergoing electrical cardioversion (ECV) for atrial fibrillation (AF). Vitamin K antagonists greatly reduce the risk of thromboembolic events, but the administration scheme before ECV is troublesome as difficulties in reaching and maintaining the target therapeutic range for 3 weeks often delay the restoration and likelihood of maintaining sinus rhythm. Low molecular weight heparins (LMWHs) do not need dose adjustment, and may be preferable in this clinical setting. In this multicentre study, the LMWH parnaparin was used at a dose of 85 anti-factor Xa U/kg b.i.d. 2 weeks before and 3 weeks after ECV of AF. In an intention to treat analysis of 102 patients, there was no systemic thromboembolism or major bleeding (0%, 95% CI 0–3.6). Two clinically relevant non-major bleeds (2.5%, 95% CI 0.7–8.8) and three minor bleeds (3.8%, 95% CI 1.3–10.6) were recorded. No heparin-induced thrombocytopenia or other major adverse events were recorded. Parnaparin appears effective and safe for thromboprophylaxis of elective ECV in patients with AF.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, D’Agostino RB, Massaro JM, Beiser A, Wolf PA, Benjamin EJ (2004) Lifetime risk for development of atrial fibrillation: the Framingham heart study. Circulation 110:1042–1046

    Article  PubMed  Google Scholar 

  2. Freestone B, Lip GYH (2003) Epidemiology and costs of cardiac arrhythmias. In: Lip GYH, Godtfredsen J (eds) Cardiac arrhythmias: a clinical approach. Mosby, Edinburgh

    Google Scholar 

  3. Heeringa J, van der Kuip DA, Hofman A, Kors JA, van Herpen G, Stricker BH, Stijnen T, Lip GY, Witteman JC (2006) Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 27:949–953

    Article  PubMed  Google Scholar 

  4. Krahn AD, Manfreda J, Tate RB, Mathewson FA, Cuddy TE (1995) The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba follow-up study. Am J Med 98:476–484

    Article  PubMed  CAS  Google Scholar 

  5. Wyse DG, Waldo AL, Di Marco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD, Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators (2002) A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 347:1825–1833

    Article  PubMed  CAS  Google Scholar 

  6. Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG, Crijns HJ, Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group (2002) A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 347:1834–1840

    Article  PubMed  Google Scholar 

  7. Lown B (1967) Electrical reversion of cardiac arrhythmias. Br Heart J 29:469–489

    Article  PubMed  CAS  Google Scholar 

  8. Gallagher MM, Guo XH, Poloniecki JD, Guan Yap Y, Ward D, Camm AJ (2001) Initial energy setting, outcome and efficiency in direct current cardioversion of atrial fibrillation and flutter. J Am Coll Cardiol 38:1498–1504

    Article  PubMed  CAS  Google Scholar 

  9. Lown B, Amarasingham R, Neuman J (1962) New method for terminating cardiac arrhythmias. Use of synchronized capacitor discharge. JAMA 182:548–555

    PubMed  CAS  Google Scholar 

  10. Berger M, Schweitzer P (1998) Timing of thromboembolic events after electrical cardioversion of atrial fibrillation or flutter: a retrospective analysis. Am J Cardiol 82:1545–1547

    Article  PubMed  CAS  Google Scholar 

  11. Fatkin D, Kuchar DL, Thorburn CW, Feneley MP (1994) Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for “atrial stunning” as a mechanism of thromboembolic complications. J Am Coll Cardiol 23:307–316

    Article  PubMed  CAS  Google Scholar 

  12. Black IW, Fatkin D, Sagar KB, Khandheria BK, Leung DY, Galloway JM, Feneley MP, Walsh WF, Grimm RA, Stollberger C (1994) Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study. Circulation 89:2509–2513

    PubMed  CAS  Google Scholar 

  13. Maltagliati A, Galli CA, Tamborini G, Calligaris A, Doria E, Salehi R, Pepi M (2006) Usefulness of transoesophageal echocardiography before cardioversion in patients with atrial fibrillation and different anticoagulant regimens. Heart 92:933–938

    Article  PubMed  CAS  Google Scholar 

  14. Dettori AG (1995) Parnaparin: a review of its pharmacological profile and clinical application. Drugs Today 31:19–35

    CAS  Google Scholar 

  15. Zhao L, Zhang Z, Kolm P, Jasper S, Lewis C, Klein A, Weintraub W, ACUTE II Investigators (2008) Cost in the use of enoxaparin compared with unfractionated heparin in patients with atrial fibrillation undergoing a transesophageal echocardiography-guided cardioversion (from assessment of cardioversion using transesophageal echocardiography [ACUTE II] randomized multicenter study). Am J Cardiol 101:338–342

    Article  PubMed  CAS  Google Scholar 

  16. Frampton JE, Faulds D (1994) Parnaparin: a review of its pharmacology, and clinical application in the prevention and treatment of thromboembolic and other vascular disorders. Drugs 47:652–676

    Article  PubMed  CAS  Google Scholar 

  17. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001) Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 285:2864–2870

    Article  PubMed  CAS  Google Scholar 

  18. Pengo V, Cucchini U, Denas G, Erba N, Guazzaloca G, La Rosa L, De Micheli V, Testa S, Frontoni R, Prisco D, Nante G, Iliceto S, Italian Federation of Centers for the Diagnosis of Thrombosis and Management of Antithrombotic Therapies (FCSA) (2009) Standardized low-molecular-weight heparin bridging regimen in outpatients on oral anticoagulants undergoing invasive procedure or surgery: an inception cohort management study. Circulation 119:2920–2927

    Article  PubMed  CAS  Google Scholar 

  19. Manning WJ, Silvermann DI, Katz SE, Riley MF, Come PC, Doherty RM, Munson JT, Douglas PS (1994) Impaired left atrial function after cardioversion: relationship to the duration of atrial fibrillation. J Am Col Cardiol 23:1535–1540

    Article  CAS  Google Scholar 

  20. Singer DE, Albers GW, Dalen JE, Fang MC, Go AS, Halperin JL, Lip GYH, Mannin WJ (2008) Antithrombotic Therapy in Atrial fibrillation. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 33(6 Suppl.):546S–592S

    Article  Google Scholar 

  21. Stellbrink C, Hanrath P (2000) The optimal management of cardioversion of atrial fibrillation or flutter: still stunning problem. Eur Heart J 21:795–798

    Article  PubMed  CAS  Google Scholar 

  22. Yigit Z, Küçükoglu MS, Okçün B, Sansoy V, Güzelsoy D (2003) The safety of low-molecular weight heparins for the prevention of thromboembolic events after cardioversion of atrial fibrillation. Jpn Heart J 44(3):369–377

    Article  PubMed  CAS  Google Scholar 

  23. Klein AL, Grimm RA, Murray RD, Apperson-Hansen C, Asinger RW, Black IW, Davidoff R, Erbel R, Halperin JL, Orsinelli DA, Porter TR, Stoddard MF for the Assessment of Cardioversion Using Transesophageal Echocardiography Investigators (2001) Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 344:1411–1420

    Article  PubMed  CAS  Google Scholar 

  24. Stellbrink C, Nixdorff U, Hofmann T, Lehmacher W, Daniel WG, Hanrath P, Geller C, Mügge A, Sehnert W, Schmidt-Lucke C, Schmidt-Lucke JA, ACE (Anticoagulation in Cardioversion using Enoxaparin) Study Group (2004) Safety and efficacy of enoxaparin compared with unfractionated heparin and oral anticoagulants for prevention of thromboembolic complications in cardioversion of nonvalvular atrial fibrillation. The Anticoagulation in Cardioversion using Enoxaparin (ACE) Trial. Circulation 109:997–1003

    Article  PubMed  CAS  Google Scholar 

  25. Schmidt-Lucke C, Paar WD, Stellbrink C, Nixdorff U, Hofmann T, Meurer J, Grewe R, Daniel WG, Hanrath P, Mügge A, Klein HU, Schmidt-Lucke JA (2007) Quality of anticoagulation with unfractionated heparin plus phenprocoumon for the prevention of thromboembolic complications in cardioversion for non-valvular atrial fibrillation. Sub-analysis from the anticoagulation in Cardioversion using Enoxaparin (ACE) trial. Thrombosis Res 119:27–34

    Article  CAS  Google Scholar 

  26. Roijer A, Eskilsson J, Olsson B (2000) Transesophageal echocardiography guided cardioversion of atrial fibrillation or flutter. Eur Heart J 21:837–847

    Article  PubMed  CAS  Google Scholar 

  27. Murray RD, Shah A, Jasper SE, Goodman A, Deitcher SR, Katz WE, Malouf JF, Stoddard MF, Grimm RA, Klein AL, ACUTE II pilot study (2000) Transesophageal echocardiography guided enoxaparin antithrombotic strategy for cardioversion of atrial fibrillation: the ACUTE II pilot study. Am Heart J 139:1–7

    Article  Google Scholar 

  28. Klein AL, Jasper SE, Katz WE, Malouf JF, Pape LA, Stoddard MF, Apperson-Hansen C, Lieber EA, ACUTE II Steering and Publications Committee for the ACUTE II Investigators (2006) The use of enoxaparin compared with unfractionated heparin for short- term antithrombotic therapy in atrial fibrillation patients undergoing transoesophageal echocardiography-guided cardioversion: Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) II randomized multicentre study. Eur Heart J 27:2858–2865

    Article  PubMed  CAS  Google Scholar 

  29. Elliott DJ, Zhao L, Jasper SE, Lieber EA, Klein AL, Weintraub WS (2008) Health status outcomes after cardioversion for atrial fibrillation: results from the assessment of cardioversion using transesophageal echocardiography (ACUTE) II trial. Am Heart J 156:1–6

    Article  Google Scholar 

  30. De Luca I, Sorino M, De Luca L, Colonna P, Del Salvatore B, Corlianò L (2005) Pre- and post-cardioversion transesophageal echocardiography for brief anticoagulation therapy with enoxaparin in atrial fibrillation patients: a prospective study with a 1-year follow-up. Int J Cardiol 102:447–454

    Article  PubMed  Google Scholar 

  31. McKeage K, Keating GM (2008) Parnaparin: a review of its use in the management of venous thromboembolism, chronic venous disease and other vascular disorders. Drugs 68:105–122

    Article  PubMed  CAS  Google Scholar 

  32. Camporese G, Bernardi E, Noventa F (2009) Update on the clinical use of the low-molecular-weight heparin, parnaparin. Vasc Health Risk Manag 5:819–831

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

The authors thank Alfa Wassermann SpA, Bologna, Italy for supplying the parnaparin, Maria Grimaldi, MD and Jackie Leeder, BSc of the Clinical Research Department for their support in the management of this study. Alfa Wassermann SpA, Bologna, Italy sponsored the study and provided the study drug.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Department of Heart and Vessels, Careggi Hospital, University of Florence, Florence, Italy

    Giulia Angeloni

  2. Department of Cardiovascular Diseases, Sacred Heart Catholic University, Rome, Italy

    Giulia Angeloni & Enrico Romagnoli

  3. Research Laboratory, Sacred Heart Catholic University, Rome, Italy

    Silvia Alberti

  4. Cardiologia Oncologica, Veneto Region Institute of Oncology, Padua, Italy

    Alberto Banzato

  5. Department of Cardiology, Civil Hospital, Este, Italy

    Marco Formichi

  6. Clinical Cardiology, Thrombosis Centre, University of Padua School of Medicine, Padua, Italy

    Umberto Cucchini & Vittorio Pengo

Authors
  1. Giulia Angeloni
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Silvia Alberti
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Enrico Romagnoli
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Alberto Banzato
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Marco Formichi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Umberto Cucchini
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Vittorio Pengo
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vittorio Pengo.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Angeloni, G., Alberti, S., Romagnoli, E. et al. Low molecular weight heparin (parnaparin) for cardioembolic events prevention in patients with atrial fibrillation undergoing elective electrical cardioversion: a prospective cohort study. Intern Emerg Med 6, 117–123 (2011). https://doi.org/10.1007/s11739-010-0479-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11739-010-0479-1

Keywords

Search

Navigation