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Thromboembolic events following cardioversion of acute atrial fibrillation and flutter: a systematic review and meta-analysis

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Abstract

Background

Recent studies have presented concerning data on the safety of cardioversion for acute atrial fibrillation and flutter. We conducted this meta-analysis to evaluate the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter patients of < 48 h in duration.

Methods

We searched MEDLINE, Embase, and Cochrane from inception through February 6, 2020 for studies reporting thromboembolic events post-cardioversion of acute atrial fibrillation and flutter. Main outcome was thromboembolic events within 30 days post-cardioversion. Primary analysis compared thromboembolic events based on oral anticoagulation use versus no oral anticoagulation use. Secondary analysis was based on baseline thromboembolic risk. We performed meta-analyses where 2 or more studies were available, by applying the DerSimonian-Laird random-effects model. Risk of bias was assessed with the Quality in Prognostic Studies tool.

Results

Of 717 titles screened, 20 studies met inclusion criteria. Primary analysis of seven studies with low risk of bias demonstrated insufficient evidence regarding the risk of thromboembolic events associated with oral anticoagulation use (RR = 0.82 where RR < 1 suggests decreased risk with oral anticoagulation use; 95% CI 0.27 to 2.47; I2 = 0%). Secondary analysis of 13 studies revealed increased risk of thromboembolic events with high baseline thromboembolic risk (RR = 2.25 where RR > 1 indicates increased risk with higher CHADS2 or CHA2DS2-VASc scores; 95% CI 1.25 to 4.04; I2 = 0%).

Conclusion

Primary analysis revealed insufficient evidence regarding the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter, though the event rate is low in contemporary practice. Our findings can better inform patient-centered decision-making when considering 4-week oral anticoagulation use for acute atrial fibrillation and flutter patients.

Résumé

Contexte

Des études récentes ont présenté des données sur la sécurité de la cardioversion pour la fibrillation auriculaire aiguë et le flutter. Nous avons mené cette méta-analyse pour évaluer l'effet de l'utilisation de l'anticoagulation orale sur les événements thromboemboliques post-cardioversion de patients atteints de fibrillation auriculaire aiguë à faible risque et de flutter de moins de 48 heures.

Les méthodes

Nous avons recherché dans MEDLINE, Embase et Cochrane depuis le début jusqu'au 6 février 2020 des études faisant état d'événements thromboemboliques après une cardioversion de la fibrillation auriculaire aiguë et du flutter. Le principal résultat a été des événements thromboemboliques dans les 30 jours suivant la cardioversion. L'analyse primaire a comparé les événements thromboemboliques basés sur l'utilisation de l'anticoagulation orale par rapport à l'absence d'anticoagulation orale. L'analyse secondaire était basée sur le risque thromboembolique de base. Nous avons effectué des méta-analyses lorsque deux études ou plus étaient disponibles, en appliquant le modèle à effets aléatoires DerSimonian-Laird. Le risque de biais a été évalué avec l'outil Quality in Prognostic Studies.

Résultats

Sur les 717 titres examinés, 20 études ont répondu aux critères d'inclusion. L'analyse primaire de sept études présentant un faible risque de biais a démontré l'insuffisance des preuves concernant le risque d'événements thromboemboliques associés à l'utilisation d'anticoagulation orale (RR = 0,82 où RR < 1 suggère une diminution du risque avec l'utilisation d'anticoagulation orale ; IC 95 % 0,27 à 2,47 ; I2 = 0 %). L'analyse secondaire de 13 études a révélé un risque accru d'événements thromboemboliques avec un risque thromboembolique de base élevé (RR = 2,25 où RR > 1 indique un risque accru avec des scores CHADS2 ou CHA2DS2-VASc plus élevés ; 95 % CI 1,25 à 4,04 ; I2 = 0 %).

Conclusions

L'analyse primaire a révélé des preuves insuffisantes concernant l'effet de l'utilisation de l'anticoagulation orale sur les événements thromboemboliques après une cardioversion de fibrillation auriculaire aiguë à faible risque et de flutter, bien que le taux d'événements soit faible dans la pratique contemporaine. Nos conclusions peuvent mieux éclairer la prise de décision centrée sur le patient lorsqu'il s'agit d'envisager l'utilisation de l'anticoagulation orale pendant 4 semaines pour les patients souffrant de fibrillation auriculaire aiguë et de flutter.

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Acknowledgements

We would like to thank Risa Shorr for her assistance with conducting the literature search. We would also like to acknowledge the contributions of the research staff at The Ottawa Hospital Research Institute for their involvement in the study: Cathy Clement, Angela Marcantonio, My-Linh Tran, Marie-Joe Nemnom, and Jennifer Brinkhurst.

Funding

This study received no specific grant or source of funding from any funding agency, commercial or not-for-profit sector.

Author information

Authors and Affiliations

  1. Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada

    Brenton M. Wong, Jeffrey J. Perry, Bo Zheng, Kevin Guo & Ian G. Stiell

  2. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada

    Jeffrey J. Perry, Wei Cheng, Monica Taljaard & Ian G. Stiell

  3. School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

    Jeffrey J. Perry & Monica Taljaard

  4. Division of Cardiology, Western University, London, ON, Canada

    Allan C. Skanes

  5. Clinical Epidemiology Unit, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada

    Ian G. Stiell

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  1. Brenton M. Wong
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Contributions

BMW, JJP, and IGS conceived the study idea and developed the study protocol. BMW, JJP, WC, BZ, KG, and IGS coordinated the systematic review. BMW, BZ, and KG screened abstracts and full texts, acquired the data, and assessed risk of bias in the studies. WC performed all the statistical analyses. BMW prepared the manuscript. All authors critically revised the manuscript for intellectual content and provided their permission to publish the manuscript. BMW is guarantor.

Corresponding author

Correspondence to Ian G. Stiell.

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All of the authors have no conflicts of interest to declare.

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Wong, B.M., Perry, J.J., Cheng, W. et al. Thromboembolic events following cardioversion of acute atrial fibrillation and flutter: a systematic review and meta-analysis. Can J Emerg Med 23, 500–511 (2021). https://doi.org/10.1007/s43678-021-00103-0

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