Related Subjects:
|AF - General
|AF and Anticoagulation
|AF and Rate Control
|AF and Rhythm Control and Cardioversion
|AF ECG
|DC cardioversion
Cardioversion should only be attempted if the patient has been anticoagulated for at least 3–4 weeks OR AF is definitely known to have started within the past 48 hours.
Otherwise, risk of embolic stroke is high. TOE/TEE may be required to exclude atrial thrombus.
📌 Indications
- Fast AF with haemodynamic instability (shock, hypotension, chest pain, pulmonary oedema).
- Recent AF (<3 months) where rhythm control is desirable.
- Young patient without structural heart disease.
- Persistent symptoms despite rate control.
- ⚠️ Relapse risk: 80–90% at 1 year.
🚨 Emergency Cardioversion
- If already anticoagulated → low risk → proceed directly.
- If not anticoagulated and AF >24–48h → TOE/TEE to exclude LA thrombus (if feasible).
- If unstable → immediate DC cardioversion regardless of anticoagulation status (anticoagulate after).
⚡ Cardioversion Options
- Treat reversible causes first (sepsis, thyroid disease, alcohol, electrolytes).
- Anticoagulate with LMWH or DOAC (start before or immediately after cardioversion).
- Option 1: DC Cardioversion
- Synchronised DC shock under sedation or GA.
- Preferred in haemodynamically unstable AF or where drug therapy fails.
- Option 2: Chemical Cardioversion
- Flecainide 2 mg/kg IV (max 150 mg) over 30–60 min or 300 mg PO.
⚠️ Only if normal LV and no significant IHD.
- Amiodarone IV: preferred in LV dysfunction or structural heart disease.
- Post-cardioversion: Anticoagulate for ≥4 weeks even if sinus rhythm restored.
🔄 Rhythm Control Principles
- Immediate cardioversion possible if AF <48h or TOE excludes thrombus.
- If AF >48h: anticoagulate ≥4 weeks before and ≥4 weeks after elective cardioversion.
- Drug choices:
- Amiodarone: use in LV dysfunction or structural heart disease.
- Flecainide: use if LV normal, no IHD.
- DC shock: if urgent or drugs fail.
📚 Reference
