Atrial Fibrillation: Cardioversion

Question 1

What are the 2 scenarios where cardioversion may be used in atrial fibrillation?

Answer 1

1. Electrical cardioversion - if the patient is haemodynamically unstable.
2. Electrical or chemical cardioversion - as elective when trying to get the heart back into sinus rhythm.

Question 2

When should you consider elective electrical cardioversion versus rate control?

Answer 2

If the onset of the arrhythmia is < 48 hours.

If more than 48 hours or uncertain - go for rate control.

Question 3

Patient has had AF for >48 hours. The cardiologist decides for rhythm control. How long should they be on Warfarin before elective cardioversion?

Answer 3

They should have been on Warfarin 3 weeks prior to elective cardioversion.

Question 4

Patient has had AF for >48 hours. The cardiologist decides for rhythm control. The patient isn’t on Warfarin and the cardiologist wants to do it today. What strategy can he take?

Answer 4

He can perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus.

Once excluded, he can give LMWH and cardiovert immediately.

Question 5

Do NICE prefer electrical or chemical cardioversion?

Answer 5

Electrical

Question 6

If there is high risk of electrical cardioversion failure (e.g. previous failure or AF recurrence), what should be done?

Answer 6

4 weeks of amiodarone or sotalol prior to electrical cardioversion.

Question 7

How long should patients be anticoagulated after electrical cardioversion?

Answer 7

Atleast 4 weeks.

After this, further anticoagulation is decided upon on an individual basis.