Thread by @kevin_domingues

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#echofirst #CardioTwitter
What's your take on AF/AFL cardioversion in HFrEF?

71 yo ♂️
DCM. Recent AF with worsening of HF.
On DOAC >3 weeks. 👌
Would surely benefit from cardioversion, right? 👍

But where there's smoke...

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...there's fire! 🔥

#echofirst

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ESC AF Guidelines 2020: If already on therapeutic OAC (minimum 3 weeks) - proceed with cardioversion (I-B).

But AF/AFL cardioversion in HFrEF doesn't feel that straightforward.

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Out of curiosity, the C in the CHA2DS2-VASc score refers to 'congestive HF' and it is based on a registry which included pts with 'heart failure’ or ‘LVEF <35%’ - probably many HFpEF pts as well.

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Looking at DOAC cardioversion trials specifically (all positive), it is difficult to be sure whether this "no-imaging-for-cardioversion-if-on-OAC" strategy is that safe. 🤔

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➡️X-VeRT ~18% with congestive HF, no mention on EF
➡️EMANATE ~7% with LVEF <40%
➡️ENSURE-AF ~40% with congestive HF, no mention on EF
🚫No dedicated dabigatran trial

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Actually,
This ENSURE-AF post hoc analysis showed that age and HF were independent risk factors for LA thrombi.
doi.org/10.1093/europa…

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And this meta-analysis showed similar results: age and chronic HF (OR: 3.67, 95 %CI: 2.40-5.60) were the strongest predictors of left atrial thrombus. doi.org/10.1160/th15-0…

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In summary,

⚡️AF/AFL cardioversion in HFrEF patients
👀Take a look or trust luck? 🤞

What's your take?

@NMerke @echo_stepbystep @alexsfelixecho @iamritu @VDelgadoGarcia @EACVIPresident @dr_benoy_n_shah @StellEkaterina @echotalk
@EM_RESUS @Ivan_Echocardio @VerwerftJan

@EchoSoliman @Ph_Bertrand @mjschuuring @drjohnm @KardiologieHH @kardioklick @juliogilpereira @Manuel_O_Santos @MSBBrandao @First10EM @precordialthump @iceman_ex @KemalogluOz @ACVCPresident @EHRAPresident @escardio