What are the AHA/ACC/HRS guidelines for cardioversion in patients with holiday heart syndrome (HHS)?

Updated: May 30, 2018
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jose M Dizon, MD  more...
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The American Heart Association (AHA)/2014 American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guidelines provide the following recommendations regarding cardioversion of atrial fibrillation (AF) [30] :

  • 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) usedanticoagulation 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

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