Antonielli E, Pizzuti A, Gandolfo N, Sclavo M, Tanga M, Riva G, Leonardi G, Bassignana A, Di Leo M
Divisione di Cardiologia Ospedale SS. Annunziata Savigliano (CN).
G Ital Cardiol. 1997 Aug;27(8):803-10.
Several weeks of prophylactic anticoagulation are routinely prescribed before and after electrical cardioversion of atrial fibrillation. Recent studies have supported the use of transesophageal echocardiography to guide early cardioversion: patients in whom no thrombus is observed are treated with heparin followed by one month of warfarin therapy after the procedure. This kind of treatment requires hospital admission during heparin infusion, because of the need for monitoring partial thromboplastin time.
To evaluate if a short at-home treatment (three days) with warfarin is sufficient to reach a good level of anticoagulation, in order to permit safe electrical cardioversion in day-hospital for patients who show no thrombi on transesophageal echocardiography.
One hundred twenty-four patients with atrial fibrillation, who were candidates for cardioversion, were treated with warfarin: 10 mg the first and second day, 5 mg the third day in group A patients (n = 79); 15 mg the first day, 10 mg the second and third day in group B patients (n = 45). On the fourth day, INR value was measured and if it was < 2, warfarin therapy was prolonged until patients reached a good level of anticoagulation. Transesophageal echocardiography was performed when the INR was > or = 2, and patients were cardioverted with DC shock if there were no thrombi. The patients were discharged on the same day of the procedure, and warfarin therapy was continued for 4 weeks there-after. If a thrombus was detected, patients repeated transesophageal echocardiography after 6 weeks of warfarin therapy, and were cardioverted if the thrombus disappeared. Otherwise, cardioversion was deferred and they received prolonged warfarin treatment. If there was poor visualization of the left atrial appendage, patients received conventional warfarin therapy for 3 weeks before and 4 weeks after electrical cardioversion.
Mean INR value after three days of warfarin treatment was 2.41 in group A patients and 3.02 in group B patients. Twenty-one patients from group A and 3 patients from group B required anticoagulant therapy for a mean of 3.3 and 5.1 days, respectively, before reaching a good level of anticoagulation (INR value > or = 2). Eight patients reverted spontaneously to sinus rhythm before transesophageal echocardiography. Eighteen thrombi (15.5%) were identified on the transesophageal echocardiography, all of which were in the left atrial appendage. In 11 cases, thrombus disappeared after 6 weeks of warfarin therapy. In 7 patients (6%), the atrial appendage was not sufficiently visualized. Electrical cardioversion was performed on 109 patients and was successful in 88 (80.7%). None of them experienced a clinical thromboembolic event.
In the majority of patients in atrial fibrillation, a short at-home warfarin treatment is sufficient to reach a good level of anticoagulation in order to permit safe electrical cardioversion in a day-hospital situation. Larger initial doses can achieve even better results. This treatment algorithm minimizes the anticoagulation period, hospital stay, overall duration of atrial fibrillation and the time required for the mechanical function of the left atrium to return.
心房颤动电复律前后通常常规给予数周预防性抗凝治疗。近期研究支持采用经食管超声心动图指导早期复律：未观察到血栓的患者先给予肝素治疗，术后再接受1个月的华法林治疗。由于需要监测部分凝血活酶时间，这种治疗在肝素输注期间需要住院。
评估华法林短期居家治疗（3天）是否足以达到良好的抗凝水平，以便在日间医院对经食管超声心动图未显示血栓的患者进行安全的电复律。
124例有复律指征的心房颤动患者接受华法林治疗：A组（n = 79）患者第1天和第2天服用10 mg，第3天服用5 mg；B组（n = 45）患者第1天服用15 mg，第2天和第3天服用10 mg。第4天测量INR值，若INR < 2，则延长华法林治疗直至患者达到良好的抗凝水平。当INR≥2时进行经食管超声心动图检查，若无血栓则对患者进行直流电休克复律。患者在操作当天出院，此后继续华法林治疗4周。若检测到血栓，患者在华法林治疗6周后重复经食管超声心动图检查，若血栓消失则进行复律。否则，推迟复律并给予延长的华法林治疗。若左心耳显示不清，患者在电复律前3周和后4周接受常规华法林治疗。
华法林治疗3天后，A组患者的平均INR值为2.41，B组患者为3.02。A组21例患者和B组3例患者在达到良好抗凝水平（INR值≥2）之前分别需要平均3.3天和5.1天的抗凝治疗。8例患者在经食管超声心动图检查前自发恢复窦性心律。经食管超声心动图检查发现18个血栓（15.5%），均位于左心耳。11例患者在华法林治疗6周后血栓消失。7例患者（6%）左心耳显示不清。109例患者进行了电复律，88例成功（80.7%）。所有患者均未发生临床血栓栓塞事件。
在大多数心房颤动患者中，华法林短期居家治疗足以达到良好的抗凝水平，以便在日间医院环境中进行安全的电复律。更大的初始剂量可取得更好的效果。这种治疗方案可将抗凝期、住院时间、心房颤动的总持续时间以及左心房机械功能恢复所需的时间降至最低。
