Find out which patients may be more suitable for pharmacological than electrical cardioversion.
In recent onset AF (Figure 15), the ESC/EHRA guidelines suggest rhythm control to improve symptoms. The guidelines also prefer rhythm to rate control in pre-excited AF (ventricles depolarise prematurely) and AF during pregnancy. Clinicians should also manage cardiovascular risk factors and help patients avoid AF triggers to facilitate sinus rhythm control.5
For patients with new onset AF who do not have a history of ischaemic or structural heart disease, flecainide, propafenone or vernakalant are options for pharmacological cardioversion. Some patients with infrequent symptomatic paroxysmal AF can self-administer a single bolus of oral flecainide or propafenone at home to restore sinus rhythm, once the treatment’s safety is established in hospital.5
Ibutilide is another option for pharmacological cardioversion in AF, provided patients do not have a history of ischaemic or structural heart disease. The ESC/EHRA guidelines recommend amiodarone in patients with ischaemic or structural heart disease or both. Vernakalant offers an alternative to amiodarone, provided patients do not have hypotension, severe heart failure or severe structural heart disease, in particular aortic stenosis.5See details about long-term antiarrhythmic drugs in the next section