What are the guidelines for cardioversion of atrial fibrillation (Afib) (AF)?

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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The 2014 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) guidelines provide the following recommendations regarding cardioversion of atrial fibrillation (AF) [1] :

  • AF of ≥48 hours’ duration, or when the duration is unknown: Warfarin anticoagulation (international normalized ratio [INR] 2-3) for at least 3 weeks before and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and the cardioversion method (electrical or pharmacological) used; anticoagulation with dabigatran, rivaroxaban, or apixaban is also reasonable

  • AF of ≥48 hours’ duration, or when the duration is unknown, requiring immediate cardioversion for hemodynamic instability: Anticoagulation should be administered as soon as possible and continued for 4 weeks after cardioversion

  • AF with high risk of stroke and < 48 hours’ duration: Administration of IV heparin or low molecular weight heparin (LMWH), factor Xa inhibitor, or direct thrombin inhibitor as soon as possible before and immediately after cardioversion, followed by long-term anticoagulation therapy

  • AF with low risk of stroke and < 48 hours’ duration: Administration of either IV heparin or LMWH, factor Xa or direct thrombin inhibitor or no antithrombotic therapy may be considered for cardioversion, without the need for postcardioversion oral anticoagulation therapy

  • For AF of any duration, long-term anticoagulation therapy should be based on the patient’s stroke risk profile

  • AF or atrial flutter of ≥48 hours’ duration: For conversion of AF of ≤7 days, agents with proven efficacy include flecainide, ibutilide, propafenone and, to a lesser degree, amiodarone

  • For conversion of AF lasting 7-90 days, agents with proven efficacy include amiodarone, ibutilide, flecainide, and propafenone

  • For conversion of AF lasting more than 90 days, oral propafenone, amiodarone, and dofetilide have been shown to be effective at converting persistent AF to normal sinus rhythm

  • Propafenone or flecainide in addition to a beta-blockers or non-dihydropyridine calcium channel antagonists is reasonable for termination of AF outside the hospital, once this treatment has been observed to be safe in a monitored setting for selected patients (“pill-in-the-pocket”)

  • Dofetilide therapy should not be initiated out of hospital because of the risk of torsade de pointes

  • Direct current cardioversion (DCC) is indicated when rapid ventricular rate does not respond promptly to medications in patients with AF and ongoing myocardial ischemia, hypotension or heart failure

  • Immediate DCC in preexcitation with rapid tachycardia or hemodynamic instability

NOTE: Repeated cardioversions may be undertaken in patients with persistent AF, provided that sinus rhythm can be maintained for a clinically meaningful period between cardioversion procedures; severity of AF symptoms and patient preference should be considered before initiation of a strategy requiring serial cardioversions

In general, the European Society of Cardiology (ESC) recommendations for cardioversion concur with the AHA/ACC/HRS guidelines. Many of the differences between the guidelines involve the use of vernakalant, which was approved for use in European Union in 2010 but has not been approved by the US Food and Drug Administration. Additional and/or variant ESC recommendations include the following [149] :

  • In the absence of structural heart disease, IV flecainide, propafenone, ibutilide, or vernakalant
  • In patients with risk factors for stroke or AF recurrence, oral anticoagulant therapy should be continued lifelong, irrespective of the apparent maintenance of sinus rhythm following cardioversion
  • In patients with AF ≤7 days and moderate structural heart disease, IV vernakalant may be considered
  • Vernakalant should be used with caution in patients with NYHA class I–II heart failure

The ESC guidelines note that vernakalant is contraindicated in patients with any of the following:

  • Hypotension (systolic blood pressure < 100 mm Hg)
  • Recent (30 days) acute coronary syndrome
  • New York Heart Association (NYHA) class III and IV heart failure
  • Severe aortic stenosis
  • QT interval prolongation (uncorrected QT >440 ms)

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