Atrial fibrillation electrical cardioversion: Difference between revisions
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki> | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki> | ||
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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>=== | |||
{|class="wikitable" | |||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' 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]]) <nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' 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]]) <nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' 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]]) <nowiki>"</nowiki> | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''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]]) <nowiki>"</nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2a.''' 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]]). 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]]) <nowiki>"</nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2b.'''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]]). 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]]) <nowiki>"</nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]]) <nowiki>"</nowiki> | |||
|} | |} | ||
Revision as of 16:25, 12 October 2012
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Atrial Fibrillation Microchapters | |
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Special Groups | |
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Diagnosis | |
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Treatment | |
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Cardioversion | |
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Anticoagulation | |
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Surgery | |
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Case Studies | |
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Atrial fibrillation electrical cardioversion On the Web | |
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Directions to Hospitals Treating Atrial fibrillation electrical cardioversion | |
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Risk calculators and risk factors for Atrial fibrillation electrical cardioversion | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Patients with hemodynamic instability should undergo electrical cardioversion (also known as direct-current or DC cardioversion) and treatment with parenteral agents to slow the heart rate down.
Electrical Cardioversion
The following scenarios warrant urgent DC cardioversion:
- The presence of cardiogenic shock or hypotension
- Decompensated heart failure
- Refractory ischemia, ischemic EKG changes
ACCF/AHA/HRS 2011 Guidelines- Direct-Current Cardioversion of Atrial Fibrillation and Flutter (DO NOT EDIT) [1][2]
| Class I |
| "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) " |
| "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) " |
| "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) " |
| Class III (Harm) |
| "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) " |
| "2. Electrical cardioversion is contraindicated in patients with digitalis toxicity or hypokalemia. (Level of Evidence: C) " |
| Class IIa |
| "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) " |
| "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) " |
ACCF/AHA/HRS 2011 Guidelines- Pharmacological Enhancement of Direct-Current Cardioversion (DO NOT EDIT) [1][2]
| Class IIa |
| "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) " |
| "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) " |
| Class IIb |
| "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) " |
| "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) " |
| "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) " |
ACCF/AHA/HRS 2011 Guidelines- Prevention of Thromboembolism in Patients With Atrial Fibrillation Undergoing Cardioversion (DO NOT EDIT) [1][2]
| Class I |
| "1. 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. (Level of Evidence: B) " |
| "2. 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. (Level of Evidence: C) " |
| "3. 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. (Level of Evidence: C) " |
| Class IIa |
| "1.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. (Level of Evidence: C) " |
| "2a. 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. (Level of Evidence: B). 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.). (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. (Level of Evidence: B) Limited data are available to support the subcutaneous administration of a low molecular weight heparin in this indication. (Level of Evidence: C) " |
| "2b.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. (Level of Evidence: 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. (Level of Evidence: C) " |
| "3. For patients with atrial flutter undergoing cardioversion, anticoagulation can be beneficial according to the recommendations as for patients with AF. (Level of Evidence: C) " |
Vote on and Suggest Revisions to the Current Guidelines
Guideline Resources
- 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation [2]
- ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter [3]
References
- ↑ 1.0 1.1 1.2 1.3 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) 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. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
- ↑ 2.0 2.1 2.2 2.3 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 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. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
- ↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) 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. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199
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