Atrial fibrillation (AF) is the most common arrhythmia present in 1% of population under 60
years of age and reaching up to 15% at 80 years. AF is associated with reduced quality of
life, increased morbidity, mortality and health economic costs.
Presentation of AF differs substantially among patients ranging from self-limiting short
episodes (paroxysmal AF), longstanding episodes (persistent AF) where direct current (DC)
cardioversion is needed, to chronic atrial fibrillation. Treatment of AF is individually
tailored in accordance to symptoms, type of AF and thromboembolic risk. The standard
treatment of symptomatic persistent AF is DC-cardioversion preceded by anticoagulant
treatment with Warfarin. According to guidelines DC-cardioversion can be performed when
anticoagulation treatment has been in therapeutic range for at least 4 weeks. However
introduction of Pradaxa (Dabigatran) has enabled an earlier DC cardioversion, reducing time
to cardioversion to a 3 week period. During anticoagulation treatment persistence of AF
contributes to left atrial remodeling and increases in inflammatory and neurohumoral
biomarkers. The prolonged duration of AF and the remodeling of the left atrium increase the
risk of AF recurrence after DC-cardioversion.
Early cardioversion of patients with persistent AF is possible if preceded by transesophageal
echocardiography (TEE). The TEE guided DC- cardioversion, as demonstrated in the ACUTE study,
is a safe and efficient alternative to conventional treatment. This treatment regime is not
routinely used in clinical practice.
The aim of this study is to compare early DC-cardioversion (within 72 hours) to conventional
treatment (Pradaxa prior to DC-cardioversion). 140 patients with persistent AF will be
randomized to early cardioversion preceded by TEE in accordance with guidelines or
conventional treatment with Pradaxa for 4 weeks prior to DC-cardioversion.
The investigators will determine the outcome in the two groups regarding:
- Left atrial function and size assessed by left atrial strain, left atrial ejection
fraction and left atrial volume.
- Inflammatory and neurohumoral biomarkers including ANP, BNP,IL6 and CRP.
- Time to recurrence of AF (AF documented by ECG or Holter monitoring)
Comprehensive transthoracic echocardiography, 12 lead ECG, biomarkers and Holter monitoring
will be performed at the time of randomization, 4 weeks, 3 month and 6 month post
DC-cardioversion. Furthermore all patients will be followed for symptomatic AF recurrence for
a period of one year. AF recurrence will be documented by 12 lead ECG.