Outcomes Following Cardioversion and Atrial Fibrillation Ablation in Patients Treated With Rivaroxaban and Warfarin in the ROCKET AF Trial

Study Questions:

Does cardioversion or catheter ablation (CA) of atrial fibrillation (AF) affect outcomes in patients anticoagulated with rivaroxaban or warfarin?


This was a post-hoc analysis of data from ROCKET AF, a randomized clinical trial of rivaroxaban versus warfarin, in 14,264 patients with AF. The subjects of the study were a subgroup of 321 patients (mean age 70 years) randomly assigned to receive rivaroxaban (n = 160) or warfarin (n = 161) who underwent electrical cardioversion (n = 143), pharmacological cardioversion (n = 142), or CA of AF (n = 79). The median duration of follow-up was 2.1 years.


The rate of hospitalization increased twofold after cardioversion/CA, with no difference between the rivaroxaban and warfarin groups. Cardioversion/CA was not associated with a significant increase in the long-term risk of stroke/systemic embolism, cardiovascular death, or all-cause mortality. The incidence of stroke/systemic embolism did not differ between the rivaroxaban group (1.88%) and the warfarin group (1.86%), nor did the incidence of death (1.88% and 3.73% in the rivaroxaban and warfarin groups, respectively).


The authors concluded that cardioversion and AF ablation do not affect the long-term risk of stroke or mortality in patients with AF anticoagulated with rivaroxaban or warfarin.


An advantage of rivaroxaban over warfarin is that monitoring of the international normalized ratio is not necessary. However, the absence of a readily available laboratory test to confirm adequate anticoagulation is a disadvantage prior to cardioversion. One must rely on a patient's assertion that he or she has been taking the rivaroxaban as prescribed. This may strengthen the case for transesophageal echocardiography prior to cardioversion in patients treated with rivaroxaban (or dabigatran), particularly in high-risk patients.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Stroke, Warfarin, Catheter Ablation

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