In Reply

In his letter, Dr. Kuklinski has highlighted the time-dependent risk of thromboembolic events associated with cardioversion in non-anticoagulated patients within the first 48 hours of atrial fibrillation. While cardioversion within 12 hours of atrial fibrillation was associated with a rate of thromboembolic events of only 0.3%, this complication rate increased to 1.1% if cardioversion was performed within 12 to 48 hours of atrial fibrillation (1). Thus, he raises the issue whether these patients should be assessed using transesophageal echocardiography prior to cardioversion and whether in non-urgent cases oral anticoagulation therapy should be initiated before cardioversion.

In our review (2), we appreciated the data of the Finnish study (3) in our reference 18 by proposing that an effective anticoagulation therapy should be in place with every cardioversion. Whether transesophageal echocardiography prior to cardioversion of atrial fibrillation with a duration of 12 to 48 hours is capable of reducing the risk of thromboembolic events has, to the best of our knowledge, not been studied to such an extent that this approach could be recommended. From a clinical point of view, this measure is perfectly justifiable. Instead of the proposed oral anticoagulation therapy prior to cardioversion of recent-onset atrial fibrillation, we think it is more practical to administer primary intravenous (unfractionated heparin) or effective subcutaneous anticoagulation therapy (for example enoxaparin) before cardioversion. Alternatively, the new oral anticoagulants could be given greater importance because of their rapid onset of action.