Afib in a young 29-yo F, < 48 hours, no cardiac history, Anticoagulate after conversion?

[DrMetal]

So I saw a 29-yo F in the ER, who was in a fight, came to the hospital for new onset AF that started during said fight. HR 130s, otherwise fine, no major trauma, just emotionally stressed. She got a dose of dilt 10 mg IV in the ER and converted back to NSR. Vitals EKG were normal thereafter, bedside echo was normal, no current or past cardiovascular history of any kind.

ER doc wanted to send her home on 4 weeks of AC . . . but I recommended not to.....b/c we know her AF was <48 hours (we know this for sure, and it was precipitated by the fight), her CHADSVASC is only +1 for being female (and she's not the right patient population to be applying chadsvasc to, i know, but for now)

Did I do the right thing (in not recommending AC)? I remember from my training that if <48 hours (and we know it for sure), if no other cardiac risk factors, low chadsvasc, you don't have to AC for 4 weeks after the intentional cardioversion (I'm assuming our 10 mg IV dilt did the trick).

Looking it up in U2D though: link I guess you could AC?
[from U2D] Anticoagulation after reversion to sinus rhythm — Though unproven in efficacy, some of our contributors recommend anticoagulation for four weeks after reversion to sinus rhythm (either spontaneous or intended) for patients with AF of less than 48 hours duration, even for those with a low CHA2DS2-VASc score. The rationale for this approach is a concern regarding the high likelihood of AF recurrence in the first month after reversion to sinus rhythm, as well as transient post-cardioversion atrial stunning in the immediate pericardioversion period. This decision may be modified in patients at very high bleeding risk.

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[timpview]

ER doc was right.. typically it’s recommended to anticoagulate 4 weeks post cardioversion regardless of symptom onset/duration as it’s speculated myocardial stunning from the cardioversion can contribute. Your thought process of less 48 hrs of symptom onset is more about the decision of needing a tee pre cardioversion.

With that said the pt will likely be fine as it’s pretty unlikely anything bad will happen without anticoagulation

 

[DrMetal]

ER doc was right.. typically it’s recommended to anticoagulate 4 weeks

Thanks for the reply. What do you think about the verbage in the U2D atricle: "Though unproven in efficacy . . .some contributors recommend" It doesn't seem like this demographic---the very young and healthy who had one bout of AF, very short in duration and quickly converted, with no other previous cardiac history---has been well studied. And that makes sense, I wouldn't expect there to be a lot of data.

Still, it doesn't make much sense to me to AC the young and healthy, just b/c they were in AF for a hot minute (one time, with no other cardiac pathology). I would be more concerned about the risks of bleeding (trauma, sports, heavy activity, fighting!) , even if just for 4 weeks. No?

 

[timpview]

Sure it’s debatable and the chance of a stroke is extremely low and the chance of a bleed on AC is also extremely low. But if that one in a ten thousand does stroke you’re toast. But you’re likely fine either way.. I think the vague wording in up to date sums it up best.

 

[greatnt249]

I think if you wanted to protect yourself, you could offer 4 weeks of anticoagulation and let the patient refuse just so you can say you had the discussion. As has been stated, there isn't really hard data to say what absolutely should be done in this situation.

That being said, she has an exceedingly high probability of doing fine the way things played out. I think the only place you run into an issue is that the ED doctor may document that he/she offered this strategy.

 

[Dark_horse2005]

Did she cardiovert? Sounds like she only converted spontaneously. If so, there’s no guideline so I would use chadsvasc to guide my decision of anticoagulation. If had cardioversion, then yes 4 weeks due to atrial stunning.

 

[greatnt249]

Did she cardiovert? Sounds like she only converted spontaneously. If so, there’s no guideline so I would use chadsvasc to guide my decision of anticoagulation. If had cardioversion, then yes 4 weeks due to atrial stunning.

This may be up for debate, but I don't believe the mechanism of how the cardioversion occurred should factor into the decision-making process of whether or not to anticoagulate.

 

[DrMetal]

Did she cardiovert? Sounds like she only converted spontaneously.

She got a single dose of 10 mg IV dilt. Did that really convert her, or did she just spont convert? I dunno.

This may be up for debate, but I don't believe the mechanism of how the cardioversion occurred should factor into the decision-making process of whether or not to anticoagulate.

True. I think it's the fact that you were in Afib at all that predisposes you to a clotting event and hence the necessity of AC. If she were in AF > 48 hours, she would definitely get the AC.

What do you guys do for postpartums? [otherwise young healthy girl, goes into labor, delivers well, but the stress of it all puts her into AF for say 20 minutes, she gets some IV labetalol (OBs love their labetalol), she converts. Otherwise fine . . . you AC her for 4 weeks?]

 

[disorder]

Did she cardiovert? Sounds like she only converted spontaneously. If so, there’s no guideline so I would use chadsvasc to guide my decision of anticoagulation. If had cardioversion, then yes 4 weeks due to atrial stunning.

Again, debated. But a leader in the field whom I trained under had stated that the stunning isn’t secondary to the method of cardioversion but directly related to the duration of AF prior to cardioversion.

 

[mayn]

In addition to what everyone else has said:

From the 2019 Afib guidelines: its a class IIb to give AC prior and none post for cardioversion in men with CHADSVASc of 0 or women with CHADSVASc of 1 and afib/flutter < 48 hours.

'Two recent retrospective studies evaluated the risk of thromboembolism in patients after cardioversion for AF lasting <48 hours. In 1 study (567 cardioversions in 484 patients), the risk of thromboembolism was nearly 5 times higher in patients without therapeutic anticoagulation than in those on therapeutic anticoagulation with either warfarin or heparin, with no events in patients with a CHA2DS2-VASc score of <2.S6.1.1-14 In the second study, for patients with AF lasting <48 hours and a CHA2DS2-VASc score ≤1, the overall event rate was low (0.4%), but this group accounted for 10 of the 38 thromboembolic events (26%) that occurred in the study.S6.1.1-13 These studies agree with prior studies of cardioversion in short-term AF.S6.1.1-20 In the absence of randomized trials, the risk of thromboembolic events should be weighed against the risk of anticoagulant-related bleeding for the individual patient.'

https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000000665

Basically.. probably fine.

 

[shouldigomd]

I wouldn't.

Think about this scenario. The ER sees holiday heart / young person with drug / stress / etc induced AF all the time and send them out of metop and a cardiology follow up. By the time I see them in the cards clinic they are in NSR. Most wouldn't AC those people because CHDS is 0, female 1 point does not count for age <60 if it is the only risk factor. Just because she converted in front of you shouldn't really change anything.

Most people with a CHDS of 0 or 1 are not in persistent or chronic AF so the assumption is they are possible bouncing back and forth.

That being said people with CHDS of 0 develop CVAs from AF and all of a sudden they have 2 points warranting AC. Some clinical judgement must be applied. If you have a clear etiology without substrate for AF then I wouldn't AC. If you have an older person with sleep apnea, COPD / smoker and a large LA .... different story even with a CHDS of 0.

 

[goodstuff33]

I'll add my two cents...depends where I am located during said event. AD Cardiologist herre and personal experience in deployed setting. No, I have not started anticoagulation downrange in low risk, CV0 patients. Many reasons beyond this thready why I didn't and can also state with confidence others before me have done the same. Stateside, I give the option to the patient after risk v discussion and document.

 

[DrMetal]

I'll add my two cents...depends where I am located during said event. AD Cardiologist herre and personal experience in deployed setting. No, I have not started anticoagulation downrange in low risk, CV0 patients. Many reasons beyond this thready why I didn't and can also state with confidence others before me have done the same. Stateside, I give the option to the patient after risk v discussion and document.

Of course, deployed I would never consider it. If I felt that there was significant history of cardiovascular disease, I'd medevac that patient and start AC upon arrival at home.

My question was more about just the young patient, no cardiac history, just has a fleeting, random bout of Afib. I think the consensus is you could go either way. I would like not AC, follow clinically. If it happens again, then definitely AC after the next cardioversion. (nobody has really studies this group, I supposed b/c it's not a common problem).