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(/* ACCF/AHA/HRS 2011 Guidelines- Prevention of Thromboembolism in Patients With Atrial Fibrillation Undergoing Cardioversion (DO NOT EDIT) Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guideline...)
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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.
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.
==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]]
|-
| 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>
|}


==Vote on and Suggest Revisions to the Current Guidelines==
==Vote on and Suggest Revisions to the Current Guidelines==

Revision as of 16:24, 12 October 2012

Conduction
Sinus rhythm
Atrial fibrillation
'
ICD-10 I48
ICD-9 427.31
DiseasesDB 1065
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.

Synonyms and related keywords: AF, Afib, fib

Overview

Rhythm control methods include electrical and chemical cardioversion:[1]

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.[1]

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.

Vote on and Suggest Revisions to the Current Guidelines

Guideline Resources

References

  1. ↑ 1.0 1.1 1.2 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. ↑ Singh BN, Connolly SJ, Crijns HJ; et al. (2007). "Dronedarone for maintenance of sinus rhythm in atrial fibrillation or flutter". N. Engl. J. Med. 357 (10): 987–99. doi:10.1056/NEJMoa054686. PMID 17804843.
  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
  4. ↑ 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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