Joseph Wiesel, MD
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Wiesel J. Cost-Effectiveness of Therapy in Nonatrial Fibrillation. Ann Intern Med. 1999;131:979. doi: 10.7326/0003-4819-131-12-199912210-00015
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Published: Ann Intern Med. 1999;131(12):979.
TO THE EDITOR:
Catherwood and colleagues (1) recommend a first attempt at cardioversion from atrial fibrillation without long-term anticoagulation. However, there is no adequate evidence of the safety of this approach. The authors assume that the risk for an embolus if the patient develops recurrent atrial fibrillation is the same as the risk that would be seen if the patient develops chronic atrial fibrillation for an average of 1.5 months. This is unlikely. Many patients who develop new-onset atrial fibrillation have episodes of transient atrial fibrillation. The Framingham Study found that 14 of 26 patients who presented with a new stroke and no previous documentation of atrial fibrillation had transient atrial fibrillation (2). This transient atrial fibrillation probably placed patients at a significantly higher risk for embolization than chronic atrial fibrillation for the same time period. This can be inferred from studies suggesting that patients with transient atrial fibrillation had the same annual risk for embolization as those with chronic atrial fibrillation (3). If the risk for embolization were simply related to the amount of time spent in atrial fibrillation, then patients with transient atrial fibrillation should be at a lower risk because they are in sinus for at least part of the time. Their risk is the same as that of patients with chronic atrial fibrillation because of the increased risk for embolization associated with spontaneous conversion to sinus rhythm. The current estimate of the risk for embolization with pharmacologic cardioversion is 1.2% to 1.5% (4). The incidence of transient atrial fibrillation after cardioversion is unknown, but this condition is likely to be common, given the Framingham data. With a risk for embolism of up to 1.5% for each episode of conversion from atrial fibrillation to sinus rhythm, the overall risk for embolization before anticoagulation becomes very high. Therefore, patients who undergo cardioversion to sinus rhythm should receive long-term anticoagulation.
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