OBJECTIVES: This study sought to investigate the outcomes following 
cardioversion or catheter ablation in patients with atrial fibrillation (AF) 
treated with warfarin or rivaroxaban.
BACKGROUND: There are limited data on outcomes following cardioversion or 
catheter ablation in AF patients treated with factor Xa inhibitors.
METHODS: We compared the incidence of electrical cardioversion (ECV), 
pharmacologic cardioversion (PCV), or AF ablation and subsequent outcomes in 
patients in a post hoc analysis of the ROCKET AF (Efficacy and Safety Study of 
Rivaroxaban With Warfarin for the Prevention of Stroke and Non-Central Nervous 
System Systemic Embolism in Patients With Non-Valvular Atrial Fibrillation) 
trial.
RESULTS: Over a median follow-up of 2.1 years, 143 patients underwent ECV, 142 
underwent PCV, and 79 underwent catheter ablation. The overall incidence of ECV, 
PCV, or AF ablation was 1.45 per 100 patient-years (n = 321; 1.44 [n = 161] in 
the warfarin arm, 1.46 [n = 160] in the rivaroxaban arm). The crude rates of 
stroke and death increased in the first 30 days after cardioversion or ablation. 
After adjustment for baseline differences, the long-term incidence of stroke or 
systemic embolism (hazard ratio [HR]: 1.38; 95% confidence interval [CI]: 0.61 
to 3.11), cardiovascular death (HR: 1.57; 95% CI: 0.69 to 3.55), and death from 
all causes (HR: 1.75; 95% CI: 0.90 to 3.42) were not different before and after 
cardioversion or AF ablation. Hospitalization increased after cardioversion or 
AF ablation (HR: 2.01; 95% CI: 1.51 to 2.68), but there was no evidence of a 
differential effect by randomized treatment (p value for interaction = 0.58). 
The incidence of stroke or systemic embolism (1.88% vs. 1.86%) and death (1.88% 
vs. 3.73%) were similar in the rivaroxaban-treated and warfarin-treated groups.
CONCLUSIONS: Despite an increase in hospitalization, there were no differences 
in long-term stroke rates or survival following cardioversion or AF ablation. 
Outcomes were similar in patients treated with rivaroxaban or warfarin. (An 
Efficacy and Safety Study of Rivaroxaban With Warfarin for the Prevention of 
Stroke and Non-Central Nervous System Systemic Embolism in Patients With 
Non-Valvular Atrial Fibrillation [ROCKET AF]; NCT00403767).