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anticoagulation, atrial fibrillation, direct current cardioversion, stroke



  1. Fus, Allison M. BSN, RN
  2. Kim, Michael H. MD
  3. Haw, Janet M. BSN, RN
  4. Trohman, Richard G. MD
  5. Stephan, Elaine


Background: Therapeutic anticoagulation before elective direct current cardioversion (DCC) of atrial fibrillation reduces the risk of embolic stroke. Direct current cardioversion is performed by a variety of practitioners, and variable adherence to preprocedural anticoagulation guidelines is common.


Objective: We assessed the impact of a written policy on guideline compliance.


Methods: Anticoagulation status and transesophageal echocardiogram (TEE) results were reviewed in 55 patients (32 men/23 women; ages 18-83 years) who underwent elective DCC during the 6-month period before a written anticoagulation policy was sent to physicians who perform, prepare, or refer patients for this procedure. The nurse assigned to each DCC was responsible for documenting anticoagulation status. In accordance with guidelines, therapeutic anticoagulation was defined as a normalized ratio range >= 2.0 for at least 3 weeks or a negative TEE with a normalized ratio range >= 2.0 or a partial thromboplastin time > 50 seconds at the time of DCC. Immediately after policy implementation, anticoagulation status and TEE results were reviewed in 53 patients (42 men/11 women; ages 21-84 years) and 1 year post-policy implementation.


Results: Before policy implementation, 14 of 52 patients (27%) had DCC performed without adequate anticoagulation or a negative TEE. Immediately postimplementation, only 2 of 50 patients (4%) had DCC performed without adequate anticoagulation or a negative TEE (P = .002). One year post-policy implementation, only 4 of 48 patients (8%) had DCC performed without adequate anticoagulation or a negative TEE (P = .03).


Conclusions: Implementing a written policy greatly reduces the number of patients undergoing DCC without adequate anticoagulation or a negative TEE. The impact of this intervention was quickly demonstrable and persisted during follow-up. Supplementing published recommendations with guideline-driven policies may reduce variations in clinical practice and improve quality of care.