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==Overview==
==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.
[[pharmacology|Pharmacological]] (also known [[Chemical substance|chemical]]) [[cardioversion]] refers to restoring the [[heart]]'s [[rhythm]] to normal through [[pharmacology|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 [[mouth|orally]] or [[Intravenous therapy|intravenously]]. The [[treatment]] can be carried either in an in-[[patient]] or out-[[patient]] setting.
==Atrial fibrillation pharmacological cardioversion==
==Atrial fibrillation pharmacological cardioversion==
*[[Patient]]'s preferences, presence of other [[Comorbidity|comorbidities]], [[Adverse effect (medicine)|adverse effects]] of the [[medications]] and chance of [[atrial fibrillation]] recurrence should be noted when [[pharmacology|pharmacologica]] [[cardioversion]] for long term is considered. <ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*[[Patient]]'s preferences, presence of other [[Comorbidity|comorbidities]], [[Adverse effect (medicine)|adverse effects]] of the [[medications]] and chance of [[atrial fibrillation]] recurrence should be noted when [[pharmacology|pharmacologica]] [[cardioversion]] for long term is considered. <ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
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**[[Antiarrhythmic agent|Class II agents]] [[Beta blockers]]
**[[Antiarrhythmic agent|Class II agents]] [[Beta blockers]]
**[[Antiarrhythmic agent|Class III agents]] such as [[Amiodarone]]
**[[Antiarrhythmic agent|Class III agents]] such as [[Amiodarone]]
*[[Antiarrhythmic agent|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]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*[[Antiarrhythmic agent|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]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*If long term [[pharmacology|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]]) <ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*If long term [[pharmacology|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 a [[contraindication]] exist).<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*[[Amiodarone]] could be a wise choice for [[atrial fibrillation]] [[patients]] with concurrent [[left ventriclr|left ventricular]] impairment or [[heart failure]].  
*[[Amiodarone]] could be a wise choice for [[atrial fibrillation]] [[patients]] with concurrent [[left ventriclr|left ventricular]] impairment ([[structural heart disease]]) or [[heart failure]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*Even in [[cardioversion|electrical cardioversion]] candidates [[amiodarone]] [[therapy]] is required in a 4 week period before the procedure and also up to 1 year period of [[amiodarone]] [[treatment]] after the [[cardioversion|electrical cardioversion]] in order to maintain the [[sinus rhythm]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*Even in [[cardioversion|electrical cardioversion]] candidates [[amiodarone]] [[therapy]] is required in a 4 week period before the procedure and also up to 1 year after the [[cardioversion|electrical cardioversion]] in order to maintain the [[sinus rhythm]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*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.  
*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.
*Avoid [[pharmacology|pharmacological]] [[cardioversion]] with [[medications]] such as [[calcium channel blockers]] and [[magnesium]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
===Pill-in-the-Pocket Strategy===
===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]]). <ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*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]]). <ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>

Latest revision as of 06:13, 3 November 2021
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Atrial fibrillation pharmacological cardioversion On the Web

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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

Pharmacological (also known 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

Pill-in-the-Pocket Strategy

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

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 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. ↑ 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.
  3. ↑ 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
  4. ↑ 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.
  5. ↑ 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
  6. ↑ 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


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