Atrial fibrillation: cardioversion: transoesophageal echocardiography did not reduce subsequent embolic events.

Clinical bottom line (level 2a)

  1. Around 2% of patients undergoing cardioversion for atrial fibrillation or flutter without anticoagulation had a subsequent thromboembolic event.
  2. Transoesophageal echocardiography before cardioversion did not reduce this rate significantly.
  3. Patients who are anticoagulated were less likely to have thromboembolic events (0.33%)
Moreyra et al: American Heart Journal 1995; 129 (1): 71-75
Expires August 2004

The study

Systematic review of all studies of
  • Patients: atrial fibrillation undergoing cardioversion
  • Intervention: transoesophageal compared with blinded
  • Outcome: thromboembolic events (stroke, TIA, or peripheral embolus occurring within 10 days of cardioversion)


    • Articles found in English using MEDline, 1966 to 1993 (search terms: 'transesophageal echocardiography', 'atrial fibrillation', 'cardioversion' and 'thromboembolic events'. ) and manual searches of recently-published abstracts, and references from review articles

    Selection criteria: see above: studies needed >10 patients with atrial fibrillation or flutter for >48 hours
    Appraisal criteria: 3 groups: patients who had phrenoesophageal echocardiography and no anticoagulation; patients who were anticoagulated; patients who were not anticoagulated
    Articles excluded if:
    • inadequate information on anticoagulation status of patients


    7 studies on transoesophageal echocardiography, and 28 control groups
    • Studies were combined directly.

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    thromboembolic event: transoesophageal echocardiography ? 5/374 1.3%
    (0.17% to 2.5%)
    thromboembolic event: anticoagulation ? 4/1221 0.33%
    (0.0071% to 0.65%)
    thromboembolic event: no anticoagulation ? 41/2050 2.0%
    (1.4% to 2.6%)

    Citation

    1. Moreyra E, Finkelhor RS, Cebul RD: Limitations of transesophageal echocardiography in the risk assessment of patients before nonanticoagulated cardioversion from atrial fibrillation and flutter: an analysis of pooled trials. American Heart Journal 1995; 129 (1): 71-75
    Contributor: Chris Ball and Clare Wotton, August 1999
    Reviewer:

    Clinical Question.
    Patient atrial fibrillation
    Intervention or Exposure transoesophageal echocardiography
    Outcome thromboembolic events following cardioversion