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| {| border="1" style="border-collapse:collapse" cellpadding="3" align="right" | | __NOTOC__ |
| | colspan="3" align="center" bgcolor="#ABCDEF" | Conduction | | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|30px|link=Atrial fibrillation resident survival guide]]|| <br> || <br> |
| | <small>Sinus rhythm</small> [[Image:Heart conduct sinus.gif|none|75px]]
| | | [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | <small>Atrial fibrillation</small> [[Image:Heart conduct atrialfib.gif|none|150px]] | |
| |} | | |} |
| {{Infobox_Disease |
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| Name = |
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| Image = |
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| Caption = |
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| DiseasesDB = 1065 |
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| ICD10 = {{ICD10|I|48||i|30}} |
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| ICD9 = {{ICD9|427.31}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000184 |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| eMedicine_mult = |
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| }}
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| {{Atrial fibrillation}} | | {{Atrial fibrillation}} |
| {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[Varun Kumar, M.B.B.S.]] | | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[Varun Kumar, M.B.B.S.]] {{Anahita}} |
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| '''''Synonyms and related keywords:''''' AF, Afib, fib
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| ==Overview== | | ==Overview== |
| Rhythm control methods include electrical and chemical [[cardioversion]]:<ref name="pmid16908781"/>
| | [[Cardioversion]] is a [[medical procedure]] by which an abnormally [[fast heart rate]] ([[tachycardia]]) or [[cardiac arrhythmia]] is converted to a [[Electrical conduction system of the heart|normal rhythm]]. When [[heart rate|rate control]] is not successful enough or when it is not able to improve the [[symptoms]] of [[patients]] [[cardioversion|rhythm control]] (either [[pharmacology|pharmacological]] or electrical) should be considered. [[Atrial fibrillation electrical cardioversion|Electrical cardioversion]] involves the restoration of normal [[heart rhythm]] through the application of a [[defibrillator]]. The [[pharmacology|pharmalogical]] method is performed with usage of [[medications]], such as [[amiodarone]], [[dronedarone]], [[procainamide]], [[ibutilide]], [[propafenone]] or [[flecainide]]. Whichever method of [[cardioversion]] is used, approximately 50% of [[patients]] [[relapse]] within one year, although the continued daily use of [[mouth|oral]] [[antiarrhythmic drugs]] may extend this period. |
| * ''Electrical cardioversion'' involves the restoration of normal heart rhythm through the application of a DC electrical shock.
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| * ''Chemical cardioversion'' is performed with drugs, such as [[amiodarone]], [[dronedarone]]<ref>{{cite journal |author=Singh BN, Connolly SJ, Crijns HJ, ''et al'' |title=Dronedarone for maintenance of sinus rhythm in atrial fibrillation or flutter |journal=N. Engl. J. Med. |volume=357 |issue=10 |pages=987–99 |year=2007 |pmid=17804843 |doi=10.1056/NEJMoa054686}}</ref>, [[procainamide]], [[ibutilide]], [[propafenone]] or [[flecainide]].
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| The main risk of cardioversion is systemic embolization of a [[thrombus]] (blood clot) from the previously fibrillating left atrium. Cardioversion should not be performed without adequate anticoagulation in patients with more than 48 hours of atrial fibrillation. Cardioversion may be performed in instances of AF lasting more than 48 hours if a [[transesophogeal echocardiogram]] (TEE) demonstrates no evidence of clot within the heart.<ref name="pmid16908781"/>
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| Whichever method of cardioversion is used, approximately 50% of patient [[relapse]] within one year, although the continued daily use of oral antiarrhythmic drugs may extend this period. The key risk factor for relapse is duration of AF, although other risk factors that have been identified include the presence of structural heart disease, and increasing age.
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| ==ACCF/AHA/HRS 2011 Guidelines- Pharmacological Cardioversion of Atrial Fibrillation (DO NOT EDIT) <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref><ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>==
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| {{cquote|
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
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| '''1.''' Administration of [[flecainide]], [[dofetilide]], [[propafenone]], or [[ibutilide]] is recommended for pharmacological [[cardioversion]] of [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
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| '''1.''' Administration of [[amiodarone]] is a reasonable option for pharmacological [[cardioversion]] of [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
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| '''2.''' A single oral bolus dose of [[propafenone]] or [[flecainide]] (“pill-in-the-pocket”) can be administered to terminate persistent [[AF]] outside the hospital once treatment has proved safe in hospital for selected patients without sinus or [[AV node]] dysfunction, [[bundle branch block]], [[QT-interval prolongation]], the [[Brugada syndrome]], or [[structural heart disease]]. Before [[antiarrhythmic medication]] is initiated, a [[beta blocker]] or non [[dihydropyridine]] [[calcium channel antagonist]] should be given to prevent rapid AV conduction in the event [[atrial flutter]] occurs. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''3.''' Administration of [[amiodarone]] can be beneficial on an outpatient basis in patients with paroxysmal or persistent [[AF]] when rapid restoration of [[sinus rhythm]] is not deemed necessary. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
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| '''1.''' Administration of [[quinidine]] or [[procainamide]] might be considered for pharmacological [[cardioversion]] of [[AF]], but the usefulness of these agents is not well established. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
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| '''1.''' [[Digoxin]] and [[sotalol]] may be harmful when used for pharmacological [[cardioversion]] of [[AF]] and are not recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
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| '''2.''' [[Quinidine]], [[procainamide]], [[disopyramide]], and [[dofetilide]] should not be started out of hospital for conversion of [[AF]] to [[sinus rhythm]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''}}
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| ==ACC / AHA Guidelines- Direct-Current Cardioversion of Atrial Fibrillation and Flutter (DO NOT EDIT) <ref name="Fuster"> Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation- Executive Summary: executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidlines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114: 700-752. PMID 16908781 </ref>==
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| {{cquote|
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| ===Class I===
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| 1. When a rapid ventricular response does not respond promptly to pharmacological measures for patients with [[AF]] with ongoing [[myocardial ischemia]], symptomatic [[hypotension]], [[angina]], or [[HF]], immediate R-wave synchronized [[direct-current cardioversion]] is recommended. ''(Level of Evidence: C)''
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| 2. Immediate [[direct-current cardioversion]] is recommended for patients with [[AF]] involving [[pre-excitation]] when very rapid [[tachycardia]] or hemodynamic instability occurs. ''(Level of Evidence: B)''
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| 3. [[Cardioversion]] is recommended in patients without hemodynamic instability when symptoms of [[AF]] are unacceptable to the patient. In case of early relapse of [[AF]] after [[cardioversion]], repeated [[direct-current cardioversion]] attempts may be made following administration of [[antiarrhythmic medication]]. ''(Level of Evidence: C)''
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| ===Class IIa===
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| 1. [[Direct-current cardioversion]] can be useful to restore [[sinus rhythm]] as part of a long-term management strategy for patients with [[AF]]. ''(Level of Evidence: B)''
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| 2. Patient preference is a reasonable consideration in the selection of infrequently repeated [[cardioversion]] for the management of symptomatic or recurrent [[AF]]. ''(Level of Evidence: C)''
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| ===Class III===
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| 1. Frequent repetition of [[direct-current cardioversion]] is not recommended for patients who have relatively short periods of [[sinus rhythm]] between relapses of [[AF]] after multiple [[cardioversion]] procedures despite prophylactic [[antiarrhythmic drug therapy]]. ''(Level of Evidence: C)''
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| 2. Electrical [[cardioversion]] is contraindicated in patients with [[digitalis]] toxicity or [[hypokalemia]]. ''(Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Pharmacological Enhancement of Direct-Current Cardioversion (DO NOT EDIT) <ref name="Fuster"> Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation- Executive Summary: executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidlines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114: 700-752. PMID 16908781 </ref>==
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| {{cquote|
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| ===Class IIa===
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| 1. Pretreatment with [[amiodarone]], [[flecainide]], [[ibutilide]], [[propafenone]], or [[sotalol]] can be useful to enhance the success of [[direct-current cardioversion]] and prevent recurrent [[atrial fibrillation]]. ''(Level of Evidence: B)''
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| 2. In patients who relapse to [[AF]] after successful [[cardioversion]], it can be useful to repeat the procedure following prophylactic administration of [[antiarrhythmic medication]]. ''(Level of Evidence: C)''
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| ===Class IIb===
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| 1. For patients with persistent [[AF]], administration of [[beta blockers]], [[disopyramide]], [[diltiazem]], [[dofetilide]], [[procainamide]], or [[verapamil]] may be considered, although the efficacy of these agents to enhance the success of [[direct-current cardioversion]] or to prevent early recurrence of [[AF]] is uncertain. ''(Level of Evidence: C)''
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| 2. Out-of-hospital initiation of [[antiarrhythmic medications]] may be considered in patients without [[heart disease]] to enhance the success of [[cardioversion]] of [[AF]]. ''(Level of Evidence: C)''
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| 3. Out-of-hospital administration of [[antiarrhythmic medications]] may be considered to enhance the success of [[cardioversion]] of [[AF]] in patients with certain forms of [[heart disease]] once the safety of the drug has been verified for the patient. ''(Level of Evidence: C)''}}
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| ==ACCF/AHA/HRS 2011 Guidelines- Prevention of Thromboembolism in Patients With Atrial Fibrillation Undergoing Cardioversion (DO NOT EDIT) <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref><ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>==
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| {{cquote|
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
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| '''1.''' Antithrombotic therapy to prevent thromboembolism is recommended for all patients with [[AF]], except those with lone [[AF]] or contraindications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
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| '''2.''' The selection of the antithrombotic agent should be based upon the absolute risks of stroke and bleeding and the relative risk and benefit for a given patient. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
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| '''3.''' For patients without mechanical heart valves at high risk of [[stroke]], chronic oral anticoagulant therapy with a vitamin K antagonist is recommended in a dose adjusted to achieve the target intensity [[INR]] of 2.0 to 3.0, unless contraindicated. Factors associated with highest risk for [[stroke]] in patients with [[AF]] are prior [[thromboembolism]] (stroke, [[TIA]], or systemic embolism) and rheumatic [[mitral stenosis]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
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| '''4.''' [[Anticoagulation]] with a vitamin K antagonist is recommended for patients with more than 1 moderate risk factor. Such factors include age 75 y or greater, [[hypertension]], [[heart failure|HF]], impaired [[LV systolic function]] ([[EF|ejection fraction]] 35% or less or fractional shortening less than 25%), and [[diabetes mellitus]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
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| '''5.''' [[INR]] should be determined at least weekly during initiation of therapy and monthly when [[anticoagulation]] is stable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
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| '''6.''' [[Aspirin]], 81–325 mg daily, is recommended as an alternative to vitamin K antagonists in low-risk patients or in those with contraindications to oral [[anticoagulation]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' | | ==Cardioversion== |
| | *When [[heart rate|rate control]] is not successful enough or when it is not able to improve the [[symptoms]] of [[patients]] [[cardioversion|rhythm control]] (either [[pharmacology|pharmacological]] or electrical) should be considered. <ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968 }} </ref> |
| | *[[cardioversion|Rhythm control]] methods include electrical and [[Chemical substance|chemical]] [[cardioversion]] ([[pharmacology|pharmacological]]):<ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref><ref name='Shea2002'>{{cite journal|title=Cardioversion|journal= Circulation|year=2002|first=Julie B.|last=Shea|coauthors=William H. Maisel|volume=106|issue=22|pages=e176–8|doi=10.1161/01.CIR.0000040586.24302.B9|url=http://circ.ahajournals.org/cgi/content/full/106/22/e176|format=|accessdate=|pmid=12451016 }}</ref><ref>{{cite journal |author=Singh BN, Connolly SJ, Crijns HJ, ''et al'' |title=Dronedarone for maintenance of sinus rhythm in atrial fibrillation or flutter |journal=N. Engl. J. Med. |volume=357 |issue=10 |pages=987–99 |year=2007 |pmid=17804843 |doi=10.1056/NEJMoa054686}}</ref> |
| | ** [[Atrial fibrillation electrical cardioversion|Electrical cardioversion]] involves the restoration of normal [[heart rhythm]] through the application of a [[defibrillator]]. |
| | ** [[Atrial fibrillation pharmacological cardioversion|Chemical cardioversion]] is performed with usage of [[medications]], such as [[amiodarone]], [[dronedarone]], [[procainamide]], [[ibutilide]], [[propafenone]] or [[flecainide]]. |
| | *In [[patients]] with [[atrial fibrillation]] more than 48 hours or even in cases that onset of [[atrial fibrillation]] is unknown it is recommended to delay [[cardioversion]] [[treatment]] until at least 3 weeks after [[anticoagulation]] [[therapy]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968 }} </ref> |
| | *The main risk of [[cardioversion]] is [[systemic embolization]] of a [[thrombus]] ([[Thrombus|blood clot]]) from the previously fibrillating [[left atrium]]. [[Cardioversion]] should not be performed without adequate [[anticoagulation]] in [[patients]] with more than 48 hours of [[atrial fibrillation]]. [[Cardioversion]] may be performed in instances of [[atrial fibrillation]] lasting more than 48 hours if a [[transesophogeal echocardiogram]] ([[transesophogeal echocardiogram|TEE]]) demonstrates no evidence of [[clot]] within the [[heart]].<ref name="pmid16908781"/> |
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| '''7.''' For patients with AF who have mechanical heart valves, the target intensity of anticoagulation should be based on the type of prosthesis, maintaining an [[INR]] of
| | *Whichever method of [[cardioversion]] is used, approximately 50% of [[patients]] [[relapse]] within one year, although the continued daily use of [[mouth|oral]] [[antiarrhythmic drugs]] may extend this period. |
| at least 2.5. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
| | *The key [[risk factor]] for relapse is duration of [[atrial fibrillation]]. Other [[risk factors]] that have been identified include the presence of [[structural heart disease]], and [[old age]]. |
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| '''8.''' Antithrombotic therapy is recommended for patients with [[atrial flutter]] as for those with [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''9.''' For patients with [[AF]] of 48-h duration or longer, or when the duration of [[AF]] is unknown, [[anticoagulation]] ([[INR]] 2.0 to 3.0) is recommended for at least 3 week prior to and 4 wk after [[cardioversion]], regardless of the method (electrical or pharmacological) used to restore [[sinus rhythm]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
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| '''10.''' For patients with [[AF]] of more than 48-h duration requiring immediate [[cardioversion]] because of hemodynamic instability, [[heparin]] should be administered concurrently (unless contraindicated) by an initial intravenous bolus injection followed by a continuous infusion in a dose adjusted to prolong the [[activated partial thromboplastin time]] to 1.5 to 2 times the reference control value. Thereafter, oral [[anticoagulation]] ([[INR]] 2.0 to 3.0) should be provided for at least 4 wk, as for patients undergoing elective [[cardioversion]]. Limited data support subcutaneous administration of [[low molecular weight heparin]] in this indication. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''11.''' For patients with [[AF]] of less than 48-h duration associated with hemodynamic instability ([[angina pectoris]], [[acute MI]], [[cardiogenic shock]], or [[pulmonary edema]]), [[cardioversion]] should be performed immediately without delay for prior initiation of [[anticoagulation]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
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| '''1.''' For primary prevention of thromboembolism in patients with nonvalvular [[AF]] who have just 1 of the following validated risk factors, anti-thrombotic therapy with either [[aspirin]] or a vitamin K antagonist is reasonable, based upon an assessment of the risk of
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| bleeding complications, ability to safely sustain adjusted chronic [[anticoagulation]], and patient preferences: age greater than or equal to 75 y (especially in female patients), [[hypertension]], [[heart failure]], impaired [[LV function]], or [[diabetes mellitus]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
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| '''2.''' For patients with nonvalvular AF who have 1 or more of the following less well validated risk factors, antithrombotic therapy with either [[aspirin]] or a vitamin K antagonist is reasonable for prevention of thromboembolism: age 65 to 74 y, female gender, or [[CAD]]. The choice of agent should be based upon the risk of bleeding complications, ability to safely sustain adjusted chronic anticoagulation, and patient preferences. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
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| '''3.''' It is reasonable to select antithrombotic therapy using the same criteria irrespective of the pattern (ie, paroxysmal, persistent, or permanent) of [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
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| '''4.''' In patients with [[AF]] who do not have mechanical prosthetic heart valves, it is reasonable to interrupt anticoagulation for up to 1 wk without substituting [[heparin]] for surgical or diagnostic procedures that carry a risk of bleeding. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''5.''' It is reasonable to reevaluate the need for anticoagulation at regular intervals. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''6.''' During the first 48 h after onset of [[AF]], the need for [[anticoagulation]] before and after [[cardioversion]] may be based on the patient’s risk of [[thromboembolism]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''7.''' As an alternative to [[anticoagulation]] prior to [[cardioversion]] of [[AF]], it is reasonable to perform [[TEE]] in search of [[thrombus]] in the LA or LAA. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
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| ''':a.''' For patients with no identifiable [[thrombus]], [[cardioversion]] is reasonable immediately after [[anticoagulation]] with [[unfractionated heparin]] (e.g., initiate by intravenous bolus injection and an infusion continued at a dose adjusted to prolong the [[activated partial thromboplastin time]] to 1.5 to 2 times the control value until oral [[anticoagulation]] has been established with a [[vitamin K antagonist]] (e.g., [[warfarin]]), as evidenced by an [[INR]] equal to or greater than 2.0.). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' Thereafter, oral [[anticoagulation]] ([[INR]] 2.0 to 3.0) is reasonable for a total [[anticoagulation]] period of at least 4 wk, as for patients undergoing elective [[cardioversion]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' Limited data are available to support the subcutaneous administration of a [[low molecular weight heparin]] in this indication. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| ''':b.''' For patients in whom [[thrombus]] is identified by [[TEE]], oral [[anticoagulation]] ([[INR]] 2.0 to 3.0) is reasonable for at least 3 week prior to and 4 week after restoration of [[sinus rhythm]], and a longer period of [[anticoagulation]] may be appropriate even after apparently successful [[cardioversion]], because the risk of [[thromboembolism]] often remains elevated in such cases. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''3.''' For patients with [[atrial flutter]] undergoing [[cardioversion]], [[anticoagulation]] can be beneficial according to the recommendations as for patients with [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
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| '''1.''' In patients 75 y of age and older at increased risk of bleeding but without frank contraindications to oral anticoagulant therapy, and in other patients with moderate risk factors for thromboembolism who are unable to safely tolerate anticoagulation at the standard intensity of [[INR]] 2.0 to 3.0, a lower INR target of 2.0 (range 1.6 to 2.5) may be considered for primary prevention of [[ischemic stroke]] and systemic embolism. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''2.''' When surgical procedures require interruption of oral anticoagulant therapy for longer than 1 wk in high-risk patients, unfractionated [[heparin]] may be administered or low-molecular-weight heparin given by subcutaneous injection, although the efficacy of these alternatives in this situation is uncertain. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''3.''' Following percutaneous coronary intervention or revascularization surgery in patients with [[AF]], low-dose [[aspirin]] (less than 100 mg per d) and/or [[clopidogrel]] (75mg per d) may be given concurrently with anticoagulation to prevent [[MI|myocardial ischemic events]], but these strategies have not been thoroughly evaluated and are associated with an increased risk of bleeding. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''4.''' In patients undergoing percutaneous coronary intervention, anticoagulation may be interrupted to prevent bleeding at the site of peripheral arterial puncture, but the vitamin K antagonist should be resumed as soon as possible after the procedure and the dose adjusted to achieve an [[INR]] in the therapeutic range. [[Aspirin]] may be given temporarily during the hiatus, but the maintenance regimen should then consist of the combination of [[clopidogrel]], 75 mg daily, plus warfarin (INR 2.0 to 3.0). Clopidogrel should be given for a minimum of 1 mo after implantation of a bare metal stent, at least 3 mo for a [[sirolimus|sirolimus-eluting stent]], at least 6 mo for a [[paclitaxel|paclitaxel-eluting stent]], and 12 mo or longer in selected patients, following which warfarin may be continued as monotherapy in the absence of a subsequent coronary event. When [[warfarin]] is given in combination with clopidogrel or low-dose aspirin, the dose intensity must be carefully regulated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''5.''' In patients with AF younger than 60 y without heart disease or risk factors for thromboembolism (lone [[AF]]), the risk of thromboembolism is low without treatment and the effectiveness of [[aspirin]] for primary prevention of [[stroke]] relative to the risk of bleeding has not been established. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''6.''' In patients with [[AF]] who sustain [[ischemic stroke]] or systemic embolism during treatment with low-intensity anticoagulation (INR 2.0 to 3.0), rather than add an antiplatelet agent, it may be reasonable to raise the intensity of anticoagulation to a maximum target [[INR]] of 3.0 to 3.5. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
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| '''1.''' Long-term anticoagulation with a vitamin K antagonist is not recommended for primary prevention of [[stroke]] in patients below the age of 60 y without heart disease (lone [[AF]]) or any risk factors for thromboembolism. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''}}
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| ==Vote on and Suggest Revisions to the Current Guidelines==
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| * [[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation | The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
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| ==Guideline Resources==
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| *[http://content.onlinejacc.org/cgi/reprint/48/4/e149.pdf ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>
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| *[http://circ.ahajournals.org/content/123/10/e269.full.pdf 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>
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| *[http://circ.ahajournals.org/content/117/8/1101.full.pdf ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter] <ref name="pmid18283199">Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18283199 ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society.] ''Circulation'' 117 (8):1101-20. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.187192 DOI:10.1161/CIRCULATIONAHA.107.187192] PMID: [http://pubmed.gov/18283199 18283199]</ref>
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| ==References== | | ==References== |
| {{reflist|2}} | | {{reflist|2}} |
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| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
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| [[de:Vorhofflimmern]]
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| [[fr:Fibrillation auriculaire]]
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| [[it:Fibrillazione atriale]]
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| [[nl:Boezemfibrilleren]]
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| [[ja:心房細動]]
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| [[no:Atrieflimmer]]
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| [[pl:Migotanie przedsionków]]
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| [[ro:Fibrilaţia Atrială]]
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| [[fi:Eteisvärinä]]
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| [[zh:心房颤动]]
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| [[tr:Atriyal fibrillasyon]]
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