Atrial fibrillation cardioversion
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Sinus rhythm  |
Atrial fibrillation  | |
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| ICD-10 | I48 |
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| ICD-9 | 427.31 |
| DiseasesDB | 1065 |
| MedlinePlus | 000184 |
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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 cardioversion On the Web | |
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Directions to Hospitals Treating Atrial fibrillation cardioversion | |
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Risk calculators and risk factors for Atrial fibrillation cardioversion | |
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]
- Electrical cardioversion involves the restoration of normal heart rhythm through the application of a DC electrical shock.
- Chemical cardioversion is performed with drugs, such as amiodarone, dronedarone[2], procainamide, ibutilide, propafenone or flecainide.
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.
ACCF/AHA/HRS 2011 Guidelines- Prevention of Thromboembolism in Patients With Atrial Fibrillation Undergoing Cardioversion (DO NOT EDIT) [1][3]
| 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 [3]
- ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter [4]
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
- ↑ 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.
- ↑ 3.0 3.1 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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