Atrial Fibrillation and Rhythm Control

Related Subjects: |AF - General |AF and Anticoagulation |AF and Rate Control |AF and Rhythm Control and Cardioversion |AF ECG |DC cardioversion

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Cardioversion should only be attempted on those who have been anticoagulated for at least 3-4 weeks or AF is positively known to have started within past 48 hrs.

Indications

• Fast AF with haemodynamic life threatening changes
• AF has been present for less than 3 months
• Patient is young
• No important structural heart disease.
• However 80-90% relapse at a year

Emergency Cardioversion of AF

• If anticoagulated then there is low risk of emboli and can proceed. The difficulties are where patient is not anticoagulated and duration of AF may be more than 24-48 hrs. If Cardioversion needed then a TOE/TEE to exclude atrial thrombus but this may not be possible.

Cardioversion to sinus rhythm

• For success treat reversible causes (Cardioversion is unlikely to be successful in maintaining sinus rhythm if the precipitant is still present) Start full dose LMWH or a DOAC
• Option 1: Synchronised DC Cardioversion (see topic). DC cardioversion under sedation / General anaesthesia is the option of choice in patients with adverse signs. It is also useful in patient in whom the above chemical measure has failed. Patients should be fasted and discussed with CCU.
• Option 2: Chemical Cardioversion. Flecainide 2mg/kg iv over 30 – 60 minutes Max 150 mg or Flecainide 300 mg PO. Only use flecainide if normal echo.
• Even if successful Anticoagulate for at least one month

Rhythm control: return to SR

• Anticoagulation and cardioversion: you can electrically or chemically cardiovert immediately if you can be certain that AF duration is <48 h or a TOE shows that there is no LA appendage thrombus or it is clinical indicated due to instability.
• Start LMWH or IV Heparin or DOAC immediately and anticoagulate for at least 4 weeks.
• If AF has been present for more than 48 hrs then arrange elective cardioversion after anticoagulation for 4 weeks before and at least 3 weeks after, even if successful.
• Cardioversion
  • IV Amiodarone: if abnormal LV or structural heart disease
  • IV Flecainide: if LV function normal and no significant IHD. Give 2 mg/kg up to 150 mg
  • DC cardioversion may be appropriate. Needs sedation.

Reference

• Guidance