Population Health Research Institute, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario, Canada.
Clinica di Cardiologia ed Aritmologia, Ospedali Riuniti di Ancona, Via Conca, 71, Ancona, Italy.
Eur Heart J. 2019 Sep 21;40(36):3026-3032. doi: 10.1093/eurheartj/ehz521.
It is unknown whether cardioversion of atrial fibrillation causes thromboembolic events or is a risk marker. To assess causality, we examined the temporal pattern of thromboembolism in patients having cardioversion.
We studied patients randomized to aspirin or aspirin plus clopidogrel in the ACTIVE trials, comparing the thromboembolic rate in the peri-cardioversion period (30 days before until 30 days after) to the rate during follow-up, remote from cardioversion. Among 962 patients, the 30-day thromboembolic rate remote from cardioversion was 0.16%; while it was 0.73% in the peri-cardioversion period [hazard ratio (HR) 4.1, 95% confidence interval (CI) 2.1-7.9]. The 30-day thromboembolic rates in the periods immediately before and after cardioversion were 0.47% and 0.96%, respectively (HR 2.2, 95% CI 0.7-7.1). Heart failure (HF) hospitalization increased in the peri-cardioversion period (HR 11.5, 95% CI 6.8-19.4). Compared to baseline, the thromboembolic rate in the 30 days following cardioversion was increased both in patients who received oral anticoagulation or a transoesophageal echocardiogram prior to cardioversion (HR 7.9, 95% CI 2.8-22.4) and in those who did not (HR 4.8, 95% CI 1.6-14.9) (interaction P = 0.2); the risk was also increased with successful (HR 4.5; 95% CI 2.0-10.5) and unsuccessful (HR 10.2; 95% CI 2.3-44.9) cardioversion.
Thromboembolic risk increased in the 30 days before cardioversion and persisted until 30 days post-cardioversion, in a pattern similar to HF hospitalization. These data suggest that the increased thromboembolic risk around the time of cardioversion may not be entirely causal, but confounded by the overall clinical deterioration of patients requiring cardioversion.
目前尚不清楚房颤转复是否会导致血栓栓塞事件，或者其是否为血栓栓塞事件的风险标志物。为了评估因果关系，我们研究了接受转复治疗的患者中血栓栓塞的时间模式。
我们研究了 ACTIVE 试验中随机分配至阿司匹林或阿司匹林加氯吡格雷的患者，比较了转复前 30 天至转复后 30 天（peri-cardioversion period）与转复后随访期间的血栓栓塞率。在 962 例患者中，转复后 30 天的血栓栓塞率为 0.16%；而peri-cardioversion period 的血栓栓塞率为 0.73%[风险比 (HR) 4.1，95%置信区间 (CI) 2.1-7.9]。转复前后即刻的 30 天血栓栓塞率分别为 0.47%和 0.96%（HR 2.2，95% CI 0.7-7.1）。peri-cardioversion period 期间心力衰竭（HF）住院率增加（HR 11.5，95% CI 6.8-19.4）。与基线相比，转复后 30 天的血栓栓塞率在接受转复前口服抗凝或经食管超声心动图检查的患者（HR 7.9，95% CI 2.8-22.4）和未接受上述检查的患者（HR 4.8，95% CI 1.6-14.9）中均升高（交互 P=0.2）；成功（HR 4.5；95% CI 2.0-10.5）和不成功（HR 10.2；95% CI 2.3-44.9）转复后风险也增加。
转复前 30 天和转复后 30 天内血栓栓塞风险增加，与心力衰竭住院相似。这些数据表明，转复前后血栓栓塞风险增加可能不完全是因果关系，而是与需要转复治疗的患者整体临床恶化有关。
