Anticoagulation in Electrical Cardioversion in Atrial Fibrillation
A 68-year-old female with a past medical history of hypertension, remote ischemic cerebrovascular accident , type II diabetes mellitus, heart failure with preserved ejection fraction, and chronic kidney disease (CKD 3 with creatinine clearance [CrCl] of 40 mL/min) presents with progressive shortness of breath and palpitations for the past five days. A 12-lead electrocardiogram reveals atrial fibrillation (AF) with rapid ventricular response to 135 beats per minute and no acute ischemic changes; blood pressure is 134/70 mm Hg. She is admitted, started on metoprolol, and anticoagulated with unfractionated heparin given her CHA2DS2-VASc score of 7. On the third day of her hospital stay she continues to have symptomatic AF with a rapid ventricular response to 127, despite uptitration of metoprolol and a trial of diltiazem. Blood pressure remains stable. The cardiology team decides to attempt synchronized cardioversion, but the morning activated partial thromboplastin time (aPTT) is 40 seconds. Transesophageal echocardiogram (TEE) is performed, which excludes a left atrial thrombus.
Of the following, which is the best approach to anticoagulation for cardioversion in this patient?