Electrical cardioversion is a cornerstone of AF care, but patients still need effective anticoagulation and pretreatment.
Initially, many AF patients require ventricular rate control to reduce the risk that tachycardia will cause cardiomyopathy and CHF, even if the patient does not show left ventricular systolic dysfunction.6 Nevertheless, 20–30% of AF patients show left ventricular dysfunction.5 Patients with emergent AF and haemodynamic instability because of very rapid ventricular rates or structural heart disease may need urgent cardioversion with one or more shocks with direct electrical current producing 200 to 300 joules to restore sinus rhythm.20,32 The electric shock synchronises with the QRS complex, which avoid triggering ventricular fibrillation.32
Elective electrical cardioversion (defibrillation) is the treatment of choice for AF associated with haemodynamic instability. In other cases of symptomatic persistent or long-standing persistent AF, patient and physician influence the choice between pharmacological and electrical cardioversion.5
The ESC/EHRA guidelines advocate pre-treatment with amiodarone, flecainide, ibutilide or propafenone before electrical cardioversion. The guidelines also suggest considering pre-treatment with angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) in patients with recurrent AF undergoing electrical cardioversion and receiving AADs. Pre-treatment increases the likelihood of successful cardioversion and reduces the likelihood of recurrent AF.5
The anticoagulation zone discusses stroke prevention in patients undergoing cardioversion.The next section details pharmacological cardioversion