Mrs. K is a physically active 84-year-old woman with a history of hypertension and hyperlipidemia who presented to the ED reporting 1 week of intermittent palpitations, accompanied by dyspnea and atypical chest pain. Physical exam findings were a pulse of 140 bpm, blood pressure 130\/80 mm Hg, respirations 10\/minute, oxygen saturation 100% on room air, non-distended neck veins, and clear lungs. Cardiac exam revealed irregular\/irregular tachycardia with no murmurs or gallops. Mrs. K\u2019s extremities were warm, well-perfused, and without edema. An initial electrocardiogram showed atrial fibrillation with rapid ventricular response.<\/p>\n
Mrs. K was admitted for rate control and sent for a transesophageal echocardiogram (TEE) to guide electrical cardioversion. The TEE revealed a small thrombus in the left-atrial appendage but was otherwise unremarkable\u2014normal ventricular function, no significant valvular disease. The cardioversion was canceled, and Mrs. K was discharged home on therapeutic anticoagulation and rate control. At follow-up, she reported diminished exercise capacity and mild dyspnea on exertion since her hospital discharge. Therefore, the plan was to pursue a rhythm control strategy for symptomatic atrial fibrillation.<\/p>\n
To determine whether \u2014 before electrical cardioversion \u2014 to perform a repeat TEE in a patient with atrial fibrillation, a previously identified thrombus in the left-atrial appendage, and 3 weeks of therapeutic anticoagulation, I turned to the ACUTE (Assessment of Cardioversion Using Transesophageal Echocardiography) trial<\/a>. Here are the details about this trial:<\/p>\n Investigators randomized 1222 patients with AF of at least 2 days\u2019 duration to undergo either a conventional, non\u2013TEE-guided anticoagulation strategy (lasting 3 weeks prior to cardioversion) or an early TEE-guided strategy. Patients in the TEE-guided group who had a thrombus detected were given 3 weeks of warfarin, followed by a repeat TEE. After the repeat TEE, cardioversion was performed only<\/em> if no thrombus was detected (thrombi were detected in 13.8% of the TEE-guided group).<\/p>\n During a mean follow-up of 8 weeks, incidence of the composite endpoint \u2014 cerebrovascular accident, transient ischemic attack, or peripheral embolism \u2014 was similar in the two groups (conventional, 0.5%; TEE-guided, 0.8%). The incidence of any bleeding was significantly higher in the conventional group (5.5% vs. 2.9% in the TEE-guided group), but the two groups were similar in major bleeding, death, and functional status. Normal sinus rhythm was maintained in about half of each group at 8 weeks.<\/p>\n Question:<\/strong><\/p>\n Given that the conventionally treated and TEE-guided groups in the ACUTE trial had a similar rate of embolism at follow-up and that no trial participants had precisely Mrs. K\u2019s profile \u2014 thrombus detected on initial TEE, 3 weeks of anticoagulation, and diminished exercise capacity with dyspnea on follow-up \u2014 is cardioversion without a repeat TEE an appropriate management strategy?<\/strong><\/p>\n <\/p>\n