Sandbox/Cardioversion strategy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Mugilan Poongkunran M.B.B.S [2]

Cardioversion Strategy

Shown below is an algorithm depicting the cardioversion treatment in patients with atrial fibrillation.

Abbreviations: AF: Atrial fibrillation; LA: Left atrium; TEE: Transesophageal echocardiogram

Choice of Cardioversion

Does the patient have any signs of hemodynamic instability

No

Yes

Recurrent paroxysmal or persistent AF

New onset AF

No structural heart disease

Structural heart disease

Pharmacological cardioversion

DC cardioversion

Pharmacological cardioversion

DC cardioversion

Cardioversion Strategy

Does the patient with AF has any contraindication for cardioversion : ❑ Asymptomatic elderly patients (>80 years) with multiple comorbidities ❑ Patients with high risk of bleeding

No

Yes

Anticoagulation strategy

❑ <48 hours

❑ >48 hours ❑ Unknown duration ❑ Prior history of a thromboembolism ❑ Prior history of TEE evidence of left atrial thrombus ❑ Mitral valve disease or significant cardiomyopathy or heart failure

❑ IV heparin

❑ 3 week oral anticoagulation

❑ TEE

❑ Cardioversion

No LA thrombus

LA thrombus

Sinus rhythm

Atrial fibrillation

❑ IV heparin

❑ 3 week oral anticoagulation

❑ Initiate 4 week anticoagulation therapy after cardioversion

Repeat TEE showing no LA thrombus

Repeat TEE showing LA thrombus

Cardioversion

❑ Initiate rate control & proceed with other management

Atrial fibrillation

Sinus rhythm

❑ Repeat cardioversion or use AV nodal blocking agents

❑ 4 week anticoagulation after cardioversion

Sinus rhythm

Atrial fibrillation

❑ Initiate 4 week anticoagulation therapy

❑ Initiate 4 week anticoagulation therapy ❑ Proceed with other management

Pharmacological Cardioversion Drugs & Dosages

Shown below is a table summarizing the pharmacological cardioversion for atrial fibrillation of a duration less or more than 7 days.

Pharmacological Cardioversion for Atrial Fibrillation of a Duration Up to 7 Days Drug Dosage ▸ Dofetilide (class I, level of evidence A) ▸ Oral dose depends on creatinine clearance (ml/min): ▸ > 60: 500 mg, BID ▸ 40 to 60: 250 mg, BID ▸ 20 to 40: 125 mg, BID ▸ < 20: contraindicated ▸ Flecainide (class I, level of evidence A) ▸ Oral: 200 to 300 mg ▸ Intravenous: 1.5 to 3.0 mg/kg, over 10 to 20 min ▸ Ibutilide (class I, level of evidence A) ▸ Intravenous: 1 mg over 10 min, repeat 1 mg if necessary ▸ Propafenone (class I, level of evidence A) ▸ Oral: 600 mg ▸ Intravenous: 1.5 to 2.0 mg/kg, over 10 to 20 min ▸ Amiodarone (class IIa, level of evidence A) ▸ Oral: Inpatient ▸ 1.2 to 1.8 g per day in divided dose until a maximum of 10 g ▸ Followed by a maintenance dose of 200 to 400 mg per day or 30 mg/kg Outpatient ▸ 600 to 800 mg per day divided dose until a maximum of 10 g ▸ Followed by a maintenance dose of 200 to 400 mg per day ▸ Intravenous: 5 to 7 mg/kg, over 30 to 60 min Followed by 1.2 to 1.8 g per day continuous IV OR 5 to 7 mg/kg, in divided oral doses until a maximum of 10 g Followe by a maintenance dose of 200 to 400 mg per day Pharmacological Cardioversion for Atrial Fibrillation of a Duration More Than 7 Days Drug Dosage ▸ Dofetilide (class I, level of evidence A) ▸ Oral dose depends on creatinine clearance (ml/min): ▸ > 60: 500 mg, BID ▸ 40 to 60: 250 mg, BID ▸ 20 to 40: 125 mg, BID ▸ < 20: contraindicated ▸ Ibutilide (class IIa, level of evidence A) ▸ Intravenous: 1 mg over 10 min; repeat 1 mg when necessary ▸ Amiodarone (class IIa, level of evidence A) ▸ Oral: Inpatient ▸ 1.2 to 1.8 g per day in divided dose until a maximum of 10 g ▸ Followed by a maintenance dose of 200 to 400 mg per day or 30 mg/kg Outpatient ▸ 600 to 800 mg per day divided dose until a maximum of 10 g ▸ Followed by a maintenance dose of 200 to 400 mg per day ▸ Intravenous: 5 to 7 mg/kg, over 30 to 60 min Followed by 1.2 to 1.8 g per day continuous IV OR 5 to 7 mg/kg, in divided oral doses until a maximum of 10 g Followe by a maintenance dose of 200 to 400 mg per day

References

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