Atrial fibrillation electrical cardioversion: Difference between revisions
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| [[File:Siren.gif|30px|link=Atrial fibrillation resident survival guide]]|| <br> || <br> | | [[File:Siren.gif|30px|link=Atrial fibrillation resident survival guide]]|| <br> || <br> | ||
| [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | | [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | ||
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{{Atrial fibrillation}} | {{Atrial fibrillation}} | ||
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==Overview== | ==Overview== | ||
Patients with hemodynamic instability should undergo electrical [[cardioversion]] (also known as direct-current or DC cardioversion) and treatment with parenteral agents, to slow the [[heart rate]]. | Patients with hemodynamic instability should undergo electrical [[cardioversion]] (also known as direct-current or DC cardioversion) and treatment with parenteral agents, to slow the [[heart rate]]. | ||
==Electrical Cardioversion== | ==Electrical Cardioversion== | ||
The following scenarios warrant urgent DC cardioversion: | The following scenarios warrant urgent DC cardioversion: | ||
* The presence of [[cardiogenic shock]] or [[hypotension]]. | * The presence of [[cardiogenic shock]] or [[hypotension]]. | ||
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* Refractory ischemia, ischemic EKG changes. | * Refractory ischemia, ischemic EKG changes. | ||
== | ==2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary (DO NOT EDIT)<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=Craig T.|last2=Wann|first2=L. Samuel|last3=Alpert|first3=Joseph S.|last4=Calkins|first4=Hugh|last5=Cleveland|first5=Joseph C.|last6=Cigarroa|first6=Joaquin E.|last7=Conti|first7=Jamie B.|last8=Ellinor|first8=Patrick T.|last9=Ezekowitz|first9=Michael D.|last10=Field|first10=Michael E.|last11=Murray|first11=Katherine T.|last12=Sacco|first12=Ralph L.|last13=Stevenson|first13=William G.|last14=Tchou|first14=Patrick J.|last15=Tracy|first15=Cynthia M.|last16=Yancy|first16=Clyde W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary|journal=Journal of the American College of Cardiology|year=2014|issn=07351097|doi=10.1016/j.jacc.2014.03.021}}</ref>== | ||
=== | |||
{|class="wikitable" | ===Rhythm Control=== | ||
====Thromboembolism Prevention: Recommendations==== | |||
{|class="wikitable" style="width: 80%;" | |||
|- | |- | ||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0) is recommended for at least 3 weeks prior to and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and 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 or atrial flutter of more than 48 hours 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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>''' | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' For patients with AF or atrial flutter of less than 48-hour duration and with high risk of stroke, intravenous heparin or LMWH, or administration of a factor Xa or direct thrombin inhibitor, is recommended as soon as possible before or immediately after cardioversion, followed by long- term anticoagulation therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>''' | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Following cardioversion for AF of any duration, the decision regarding long-term anticoagulation therapy should be based on the thromboembolic risk profile. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|} | |} | ||
{|class="wikitable" | {|class="wikitable" style="width: 80%;" | ||
|- | |- | ||
|colspan="1" style="text-align:center; background: | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | ||
|- | |- | ||
|bgcolor=" | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with AF or atrial flutter of 48-hour duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform a TEE prior to cardioversion and proceed with cardioversion if no LA thrombus is identified, including in the LAA, provided that anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|bgcolor=" | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for at least 3 weeks prior to and 4 weeks after cardioversion. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|} | |} | ||
{|class="wikitable | {|class="wikitable" style="width: 80%;" | ||
|- | |- | ||
| | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>''' | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with AF or atrial flutter of less than 48-hour duration who are at low | ||
thromboembolic risk, anticoagulation (intravenous heparin, LMWH, or a new oral anticoagulant) or no antithrombotic therapy may be considered for cardioversion, without the need for postcardioversion oral anticoagulation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|} | |} | ||
Revision as of 05:46, 30 March 2014
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Atrial Fibrillation Microchapters | |
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Special Groups | |
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Cardioversion | |
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Atrial fibrillation electrical cardioversion On the Web | |
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Directions to Hospitals Treating Atrial fibrillation electrical cardioversion | |
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Risk calculators and risk factors for Atrial fibrillation electrical cardioversion | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Patients with hemodynamic instability should undergo electrical cardioversion (also known as direct-current or DC cardioversion) and treatment with parenteral agents, to slow the heart rate.
Electrical Cardioversion
The following scenarios warrant urgent DC cardioversion:
- The presence of cardiogenic shock or hypotension.
- Decompensated heart failure.
- Refractory ischemia, ischemic EKG changes.
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary (DO NOT EDIT)[1]
Rhythm Control
Thromboembolism Prevention: Recommendations
| Class I |
| "1. For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0) is recommended for at least 3 weeks prior to and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and the method (electrical or pharmacological) used to restore sinus rhythm. (Level of Evidence: B)" |
| "2. For patients with AF or atrial flutter of more than 48 hours 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. For patients with AF or atrial flutter of less than 48-hour duration and with high risk of stroke, intravenous heparin or LMWH, or administration of a factor Xa or direct thrombin inhibitor, is recommended as soon as possible before or immediately after cardioversion, followed by long- term anticoagulation therapy. (Level of Evidence: C)" |
| "4. Following cardioversion for AF of any duration, the decision regarding long-term anticoagulation therapy should be based on the thromboembolic risk profile. (Level of Evidence: C)" |
| Class IIa |
| "1. For patients with AF or atrial flutter of 48-hour duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform a TEE prior to cardioversion and proceed with cardioversion if no LA thrombus is identified, including in the LAA, provided that anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks. (Level of Evidence: B)" |
| "2. For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for at least 3 weeks prior to and 4 weeks after cardioversion. (Level of Evidence: C)" |
| Class IIb |
| "1. For patients with AF or atrial flutter of less than 48-hour duration who are at low
thromboembolic risk, anticoagulation (intravenous heparin, LMWH, or a new oral anticoagulant) or no antithrombotic therapy may be considered for cardioversion, without the need for postcardioversion oral anticoagulation. (Level of Evidence: C)" |
Pharmacological Enhancement of Direct-Current Cardioversion (DO NOT EDIT) [2][3]
| Class IIa |
| "1. Pretreatment with amiodarone, flecainide, ibutilide, propafenone, or sotalol can be useful to enhance the success of direct-current cardioversion and prevent recurrent atrial fibrillation. (Level of Evidence: B)" |
| "2. In patients who relapse to AF after successful cardioversion, it can be useful to repeat the procedure following prophylactic administration of antiarrhythmic medication. (Level of Evidence: C)" |
| Class IIb |
| "1. For patients with persistent AF, administration of beta blockers, disopyramide, diltiazem, dofetilide, procainamide, or verapamil may be considered, although the efficacy of these agents to enhance the success of direct-current cardioversion or to prevent early recurrence of AF is uncertain. (Level of Evidence: C)" |
| "2. Out-of-hospital initiation of antiarrhythmic medications may be considered in patients without heart disease to enhance the success of cardioversion of AF. (Level of Evidence: C)" |
| "3. Out-of-hospital administration of antiarrhythmic medications may be considered to enhance the success of cardioversion of AF in patients with certain forms of heart disease once the safety of the drug has been verified for the patient. (Level of Evidence: C)" |
Prevention of Thromboembolism in Patients With Atrial Fibrillation Undergoing Cardioversion (DO NOT EDIT) [2][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)" |
| "2. 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). |
| a) 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) |
| b) 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)" |
Sources
- 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
- ↑ January, Craig T.; Wann, L. Samuel; Alpert, Joseph S.; Calkins, Hugh; Cleveland, Joseph C.; Cigarroa, Joaquin E.; Conti, Jamie B.; Ellinor, Patrick T.; Ezekowitz, Michael D.; Field, Michael E.; Murray, Katherine T.; Sacco, Ralph L.; Stevenson, William G.; Tchou, Patrick J.; Tracy, Cynthia M.; Yancy, Clyde W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary". Journal of the American College of Cardiology. doi:10.1016/j.jacc.2014.03.021. ISSN 0735-1097.
- ↑ 2.0 2.1 2.2 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
- ↑ 3.0 3.1 3.2 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