Atrial fibrillation electrical 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] Laith Adnan Allaham, M.D.[3]
Overview
There are numbers of indications for electrical cardioversion treatment in atrial fibrillation patients. Arrhythmia longer than 48 hours, hemodynamic instability, decompensated heart failure, and ischemia are some of the conditions the electrical cardioversion can be used.
Electrical Cardioversion
- In the atrial fibrillation that persists for longer than 48 hours electrical cardioversion is indicated.[1]
- Consider proper amiodarone therapy from 4 weeks before the electrical cardioversion and up to 1 year after it to maintain the sinus rhythm.[1]
- The following scenarios warrant urgent DC cardioversion:
- The presence of cardiogenic shock or hypotension (should be treated with parenteral agents as well).
- Decompensated heart failure.
- Refractory ischemia and ischemic EKG changes.
- It is critical to consider the following for an appropriate electrical cardioversion:
- Take note that both transoesophageal echocardiography (TOE)-guided cardioversion and conventional cardioversion are effective equally.
- Consider the transoesophageal echocardiography (TOE)-guided cardioversion only if:
- Experienced staffs are available
- Proper facilities are available
- Due to high risk of bleeding or due to the patient's preferences a short period of precardioversion anticoagulation therapy is considered
2019 AHA/ACC/HRS Focused Update of the 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 Clinical Practice Guidelines and the Heart Rhythm Society[2]
Recommendations for Prevention of Thromboembolism Referenced studies that support modified recommendations are summarized in Online Data Supplement 6
| Class I |
| 1. For patients with AF or atrial flutter of 48 hours’ duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0), a factor Xa inhibitor, or direct thrombin inhibitor is recommended for at least 3 weeks before and at least 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score or the method (electrical or pharmacological) used to restore sinus rhythm.S6.1.1-1–S6.1.1-12MODIFIED: The 2014 AF Guideline recommendation for use of warfarin around the time of cardioversion was combined with the 2014 AF Guideline recommendation for NOACs to create a single recommendation. This combined recommendation was updated to COR I/LOE B-R from COR IIa/LOE C for NOACs in the 2014 AF Guideline on the basis of additional trials that have evaluated the use of NOACs with cardioversion.(Level of Evidence: B-R)
2. For patients with AF or atrial flutter of more than 48 hours’ duration or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated.(Level of Evidence: C) 3. After cardioversion for AF of any duration, the decision about long-term anticoagulation therapy should be based on the thromboembolic risk profile and bleeding risk profile. MODIFIED: The 2014 AF Guideline recommendation was strengthened with the addition of bleeding risk profile to the long-term anticoagulation decision-making process(Level of Evidence: C-EO) |
| Class IIa |
| 4. For patients with AF or atrial flutter of less than 48 hours’ duration with a CHA2DS2-VASc score of 2 or greater in men and 3 or greater in women, administration of heparin, a factor Xa inhibitor, or a direct thrombin inhibitor is reasonable as soon as possible before cardioversion, followed by long-term anticoagulation therapy.S6.1.1-13,S6.1.1-14MODIFIED: Recommendation COR was changed from I in the 2014 AF Guideline to IIa, and LOE was changed from C in the 2014 AF Guideline to B-NR. In addition, a specific CHA2DS2-VASc score is now specified.(Level of Evidence: B-NR)
5. For patients with AF or atrial flutter of 48 hours’ duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform transesophageal echocardiography before cardioversion and proceed with cardioversion if no left atrial thrombus is identified, including in the LAA, provided that anticoagulation is achieved before transesophageal echocardiography and maintained after cardioversion for at least 4 weeks.(Level of Evidence: B) |
| Class IIb |
| 6. For patients with AF or atrial flutter of less than 48 hours’ duration with a CHA2DS2-VASc score of 0 in men or 1 in women, administration of heparin, a factor Xa inhibitor, or a direct thrombin inhibitor, versus no anticoagulant therapy, may be considered before cardioversion, without the need for postcardioversion oral anticoagulation.S6.1.1-13,S6.1.1-14,S6.1.1-16MODIFIED: Recommendation LOE was changed from C in the 2014 AF Guideline to B-NR to reflect evidence from 2 registry studies and to include specific CHA2DS2-VASc scores derived from study results.(Level of Evidence: B-NR) |
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[3]
Rhythm Control
Direct-Current Cardioversion: Recommendations
| Class I |
| "1. In pursuing a rhythm-control strategy, cardioversion is recommended for patients with AF or atrial flutter as a method to restore sinus rhythm. If cardioversion is unsuccessful, repeated direct-current cardioversion attempts may be made after adjusting the location of the electrodes, applying pressure over the electrodes, or following administration of an antiarrhythmic medication. (Level of Evidence: B)" |
| "2. Cardioversion is recommended when a rapid ventricular response to atrial fibrillation (AF) or atrial flutter does not respond promptly to pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension, or heart failure. (Level of Evidence: C)" |
| "3. Cardioversion is recommended for patients with atrial fibrillation (AF) or atrial flutter and pre-excitation when tachycardia is associated with hemodynamic instability. (Level of Evidence: C)" |
| Class IIa |
| "1. It is reasonable to perform repeated cardioversions in patients with persistent atrial fibrillation (AF) provided that sinus rhythm can be maintained for a clinically meaningful period between cardioversion procedures. Severity of atrial fibrillation AF symptoms and patient preference should be considered when embarking on a strategy requiring serial cardioversion procedures. (Level of Evidence: C)" |
Sources
- ACCF/AHA/HRS 2011 Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation[4]
- ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines[5]
- ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter[6]
References
- ↑ 1.0 1.1 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). - ↑ January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC; et al. (2019). "2019 AHA/ACC/HRS Focused Update of the 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 Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons". Circulation. 140 (2): e125–e151. doi:10.1161/CIR.0000000000000665. PMID 30686041.
- ↑ 3.0 3.1 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