0 Chads vasc score and cardioversion

Hi..my understanding, maybe wrong, is that a person with occasional afib and a 0 chads vasc score normally doesn't need to be on anti coagulation...yet if he goes in to er for cardioversion, after being in afib for more than 48 hours, normally er won't do it until he is on blood thinner for several weeks..is that just er being extra cautious about the slight chance there may be a clot that could be dislodged during the procedure?..thanks..

Basically, yes. Is it warranted? That question has been debated for years and there's still no gold standard answer.

Another option is to do a transesophageal echocardiogram (TEE) prior to the cardioversion, but most ERs aren't likely to do that because it's not commonly done in the ER. So they may not have anyone trained in the procedure on hand and paging someone and waiting for them to arrive isn't something a busy ER has time for.

Here is a paper on the topic: [pmc.ncbi.nlm.nih.gov] It has been standard of care for a long time. Was prescribed for me in 2004 during a 2.5 month episode thinking they were going to do an electro cardioversion. I ended up converting the episode with a loading dose of flecainide, and completed the anti-coagulation protocol, inlcuding the post conversion period (using warfarin in those days). I was very fit (my path to afib), age 49, and a 0 Chads score (which I think was the then scoring system).

Yes, it's a special circumstance. But if you have a TEE prior to your electrial cardioversion (ECV), you don't have to wait. I've had two TEE prior to ECV after checking into the ER, but I had to ask, as it was not offered. Later, when I understood things better, instead of having a CV right away, I scheduled a TEE and ECV as an outpatient three days out. That's because most AF episodes terminate in three days, so why ECV with a short wait. If you end up cardioverting, you cancel. Your EP will of course expect that.

So interesting story on this. In hospital overnight waiting for TEE and then ECV. They are usually done one after another, but for some reason they did the TEE first and then scheduled the ECV in a couple of hours. I think it was because they couldn't coordinate both doctors schedules, but it was a long time ago. In any event, they wheeled me back to my room after the TEE and the nurse comes in, points to the monitor and says I'm in normal rhythm. Then the EP comes by and says the same thing. I figured it was the ECV that cardioverted me and mentioned it to him. He said, no that's not possible, it was a coincidence. After he left the room the nurse came over and whispered in my ear, "Happens all the time".

Jim

Interesting study article..thank you..

Quote
Carey
Basically, yes. Is it warranted? That question has been debated for years and there's still no gold standard answer.

Another option is to do a transesophageal echocardiogram (TEE) prior to the cardioversion, but most ERs aren't likely to do that because it's not commonly done in the ER. So they may not have anyone trained in the procedure on hand and paging someone and waiting for them to arrive isn't something a busy ER has time for.

Once I was on Eliquis religious at 5mg BID and went to the ER with AF requesting an ECV. Because I flew internationally the previous days or maybe it was weeks, I was required to get a TEE. They admitted me for a few hours and did bedside and then I had my ecv. They knew me and I had racked up a dozen ecv there which was documented, but because of the flight they had insisted.

Susan: Once I was on Eliquis religious at 5mg BID and went to the ER with AF requesting an ECV. Because I flew internationally the previous days or maybe it was weeks, I was required to get a TEE.

Smart team acknowledging that continuous anticoagulation sometimes isn't a guarantee.

One of the safety signals that came out of the AVANT GUARD trial was that a clot can be lurking prior to an AF ablation even with continuou anticoagulation before.

A new trial protocol was developed incorporating TEE prior to future ablations to try and prevent any more strokes. The question is whether this protocol will start being used for ablations in general, especially for persistent.

I know it's something I will request should I need another ablation. I see the benefit to risk ratio in my favor here, as it was in your case.

Jim

My EP requested a TEE in January the day before my ablation. Probably for the same reason you suggested. That’s how they found my leaking watchman that previously wasn’t documented immediately after my implant (he checked three times), during my 6 month TEE or my 9 month TEE. I have to check if they detected my clot in my watchman during my January TEE, the day before the ablation…or during my February TEE when I developed an infection after the ablation. All I know is my hematologist is insisting I never stop 5mg BID Eliquis for procedures since I keep getting clots.