Atrial fibrillation pharmacological cardioversion
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Anahita Deylamsalehi, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Varun Kumar, M.B.B.S.
Overview
Chemical cardioversion refers to restoring the heart's rhythm to normal through pharmacological agents such as amiodarone, propafenone, and flecainide. Such medications work by altering the heart’s electrical properties to suppress the abnormal heart rhythms and restore a normal rhythm, and can be administered orally or intravenously. The treatment can be carried either in an in-patient or out-patient setting.
Atrial fibrillation pharmacological cardioversion
- Patient's preferences, presence of other comorbidities, adverse effects of the medications and chance of atrial fibrillation recurrence should be noted when pharmacologica cardioversion for long term is considered. [1]
- The following are some of the available pharmacological cardioversions for atrial fibrillation:[1]
- Class 1c antiarrhythmic drugs such as flecainide or propafenone should be avoided in atrial fibrillation patients with previous history of ischemia or structural heart disease.[1]
- If long term pharmacological cardioversion has been decided for the patient, a standard beta blocker (a beta blocker other than sotalol) could be considered as a first line treatment option. (unless there is a contraindication) [1]
- Amiodarone could be a wise choice for atrial fibrillation patients with concurrent left ventricular impairment or heart failure.
- Even in electrical cardioversion candidates amiodarone therapy is required in a 4 week period before the procedure and also up to 1 year after the electrical cardioversion in order to maintain the sinus rhythm.[1]
- If the patient is experiencing few symptoms or only experiences symptoms when there is a known trigger (such as alcohol and caffein) or if the atrial fibrillation occurs as infrequent paroxysms no treatment strategy could be considered.
Pill-in-the-Pocket Strategy
- This method only could be considered for atrial fibrillation patients with few symptoms or if the atrial fibrillation occurs as infrequent paroxysms. This method also could be selected in patients who only experience symptoms when there is a known trigger (such as alcohol and caffein). [1]
- In this strategy patients take an antiarrhythmic agent only when they have an episode of atrial fibrillation.
- Pill-in-the-pocket strategy could be selected in the presence of the following for the patients with paroxysmal atrial fibrillation:[1]
- No history of left ventricular dysfunction
- No history of ischemia or valvular heart disease
- In the presence of infrequent paroxysms with minimal symptoms
- Systolic blood pressure greater than 100 mmHg
- Resting heart rate more than 70
- Ability of patients in being educated regard how and when the pill should be taken
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation[2] (DO NOT EDIT)
Rhythm Control
Electrical and Pharmacological Cardioversion of AF and Atrial Flutter
Pharmacological Cardioversion
| Class I |
| "1. Flecainide, dofetilide, propafenone, and intravenous ibutilide are useful for pharmacological cardioversion of AF or atrial flutter provided contraindications to the selected drug are absent. (Level of Evidence: A) " |
| Class III: Harm |
| "1. Dofetilide therapy should not be initiated out of hospital owing to the risk of excessive QT prolongation that can cause torsades de pointes. (Level of Evidence: B) " |
| Class IIa |
| "1. Administration of oral amiodarone is a reasonable option for pharmacological cardioversion of AF. (Level of Evidence: A) " |
| "2. Propafenone or flecainide (“pill-in-the-pocket”) in addition to a beta blocker or nondihydropyridine calcium channel antagonist is reasonable to terminate AF outside the hospital once this treatment has been observed to be safe in a monitored setting for selected patients. (Level of Evidence: B) " |
Sources
- ACCF/AHA/HRS 2011 Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation[3]
- ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines[4]
- ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter[5]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee (2021). "Atrial fibrillation: diagnosis and management-summary of NICE guidance". BMJ. 373: n1150. doi:10.1136/bmj.n1150. PMID 34020968 Check
|pmid=value (help). - ↑ 2.0 2.1 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline 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 Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.
- ↑ 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
- ↑ Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB; et al. (2010). "ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents". Circulation. 122 (24): 2619–33. doi:10.1161/CIR.0b013e318202f701. PMID 21060077.
- ↑ 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
- ↑ 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