LETTER
Transesophageal Echocardiography-Guided Cardioversion: Going for Broke?
Allan L. Klein, MD;
R. Daniel Murray, PhD; and
Richard A. Grimm, DO
15 October 1997 | Volume 127 Issue 8 (Part 1) | Page 652
TO THE EDITOR:
In his recent editorial [1], Dr. Prystowsky discusses the ACUTE (Assessment of Cardioversion Using Transesophageal Echocardiography) Pilot Study [2]. His dissatisfaction with the study seems to stem from the stated limitations of conventional management, which include the delay of direct-current cardioversion (DCC), the increased risk for bleeding, the inconvenience of readmission for DCC, the occurrence of strokes despite anticoagulation, and the lack of controlled studies showing efficacy [2]. Prystowsky defends the conventional approach and asks "If it ain't broke, why fix it" [1].
Prystowsky indicates that use of the conventional 3-week anticoagulation period is well founded and allows for the resolution of most thrombi before DCC. Conversely, we believe that the conventional approach not only delays DCC because of subtherapeutic international normalized ratios and bleeding complications but also allows cardioversion of patients with unresolved thrombi, who may have otherwise avoided the risks of DCC through the use of transesophageal echocardiography (TEE).
We agree that the ACUTE Pilot Study did not have the power to establish efficacy, but it did emphasize that most patients (84%) who have DCC without thrombi can have successful early DCC without embolization [2]. The purpose of the study was to compare the feasibility and safety of TEE-guided cardioversion with the conventional anticoagulation management strategy for cardioversion in patients with atrial fibrillation.
We contend that the conventional approach does not stratify patients by risk, has never been tested in a randomized trial, and is not uniformly followed in clinical practice [3]. In contrast, the TEE-guided approach addresses the risk for thromboembolism, may allow earlier and more convenient DCC, and may be more cost-effective [4, 5]. However, the relative benefit of the two approaches can be established only with a large clinical trial. Rather than questioning whether the conventional approach "ain't broke," we need to "go for broke" and scientifically test the clinical efficacy and cost-effectiveness of both management approaches.
|
Author and Article Information
|
|---|
The Cleveland Clinic Foundation; Cleveland, OH 44195
1. Prystowsky EN. Management of atrial fibrillation: simplicity surrounded by controversy [Editorial]. Ann Intern Med. 1997; 126:244-6.
2. Klein AL, Grimm RA, Black IW, Leung DY, Chung MK, Vaughn SE, et al. Cardioversion guided by transesophageal echocardiography: the ACUTE Pilot Study. A randomized, controlled trial. Ann Intern Med. 1997; 126:200-9.
3. Schlicht JR, Davis RC, Naqi K, Cooper W, Rao BV. Physician practices regarding anticoagulation and cardioversion of atrial fibrillation. Arch Intern Med. 1996; 156:290-4.
4. Klein AL, Grimm RA, Black IW, Orsinelli D, Manning W, Stoddard M, et al. Cost effectiveness of TEE-guided DCC with anticoagulation compared to conventional therapy in patients with atrial fibrillation [Abstract]. J Am Coll Cardiol. 1994; 128A.
5. Seto TB, Taira DA, Tsevat J, Manning WG. Cost effectiveness of transesophageal echocardiographic-guided DCC: a decision analytic model for patients admitted to the hospital with atrial fibrillation. J Am Coll Cardiol. 1997; 29:122-30.
About Letters
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
Top
Author & Article Info
References
Article
