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Atrial Fibrillation CardioversionAka: Atrial Fibrillation Rhythm Control

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  1. See Also
    1. Guidelines 2000 CPR and Emergency Cardiovascular Care
    2. Atrial Fibrillation
    3. Atrial Fibrillation Acute Management
    4. Atrial Fibrillation Anticoagulation
    5. Atrial Fibrillation Rate Control
  2. Indications
    1. No significant left atrial enlargement
      1. Consider echocardiogram prior to cardioversion
      2. Left atrium >4.5 cm poorly maintains sinus rhythm
    2. Short duration of Atrial Fibrillation (<48 hours)
      1. Chronic Atrial Fibrillation less likely to convert
  3. Contraindications
    1. Atrial Fibrillation >48 hours without Anticoagulation
      1. Risk of embolization from atrial thrombi
      2. Early cardioversion ok if cleared with TEE first
        1. See Atrial Fibrillation Anticoagulation
  4. Admit to hospital to start Antiarrhythmics
    1. Observe for proarrhythmic effect
      1. Antiarrhythmics Class Ia and III
        1. Cause Torsades (with Prolonged QT)
        2. Incidence within first 4 days is common
    2. Admission is standard of care in U.S.
      1. Not admitted in Europe and Canada
    3. Admit especially for
      1. Antiarrhythmics Class Ia and Ic drugs
      2. Poor left ventricular function
      3. Coronary Artery Disease
      4. History proarrhythmia
    4. Admission not necessary
      1. Implanted Defibrillator in place
  5. Electrical Synchronized Cardioversion
    1. Dose: 100-360 joules (Synchronized)
    2. Conversion Rate: 67-94%
  6. Preferred agent summary
    1. No organic heart disease
      1. First choice: Flecainide or Propafenone
      2. Second choice: Sotalol
      3. Other: Amiodarone, Dofetilide
    2. Coronary Artery Disease
      1. First choice: Sotalol
      2. Second choice: Amiodarone, Dofetilide
    3. Congestive Heart Failure
      1. Amiodarone
      2. Dofetilide
    4. Left Ventricular Hypertrophy (>1.4 cm thick wall)
      1. Amiodarone
  7. Pharmacologic Cardioversion: WPW Syndrome
    1. General
      1. Consider for Atrial Fibrillation <48 hours
      2. See Atrial Fibrillation Anticoagulation for >48 hours
    2. Avoid Harmful agents
      1. Adenosine
      2. Beta Blocker
      3. Calcium Channel Blocker
      4. Digoxin
    3. Recommended agents (Use only 1 agent)
      1. Electrical Synchronized Cardioversion (See above)
      2. Class IA Agents
        1. Procainamide
      3. Class IC Agents
        1. Propafenone (Rythmol)
        2. Flecainide (Tambocor)
      4. Class III Agents
        1. Amiodarone (Cordarone)
        2. Sotalol (Betapace)
  8. Pharmacologic Cardioversion: Normal cardiac function
    1. General
      1. Consider for Atrial Fibrillation <48 hours
      2. See Atrial Fibrillation Anticoagulation for >48 hours
    2. Recommended agents (Use only 1 agent)
      1. Electrical Synchronized Cardioversion (See above)
      2. Class IA Agents
        1. Procainamide
      3. Class IC Agents
        1. Propafenone (Rythmol)
        2. Flecainide (Tambocor)
      4. Class III Agents
        1. Amiodarone (Cordarone)
        2. Ibutilide (Corvert)
  9. Pharmacologic Cardioversion: Ejection Fraction <40%
    1. General
      1. Consider for Atrial Fibrillation <48 hours
      2. See Atrial Fibrillation Anticoagulation for >48 hours
    2. Recommended agents
      1. Electrical Synchronized Cardioversion (See above)
      2. Amiodarone (Cordarone)
  10. Intermittent Atrial Fibrillation (prn use)
    1. Indications: Episodic Atrial Fibrillation
      1. Fewer than 12 Atrial Fibrillation episodes yearly
    2. Contraindications
      1. Congestive Heart Failure or other structural heart disease
      2. Coronary Artery Disease
    3. Protocol (Initiated by Cardiology)
      1. Cardiologists prescribe agent
        1. Flecainide (Tambicor) 200-300 mg
        2. Propafenone (Rhythmol) 600 mg
      2. Patient takes agent as needed at a. fib symptom onset
        1. Expect improvement within 2 hours of pill
        2. High rate of cardioversion within 8 hours
      3. ER indications
        1. No improvement in 2 hours
        2. Pulse increases after dose (atrial flutter)
      4. Safety
        1. Low Incidence of proarrhythmia
    4. References
      1. (January 2005) Prescriber's Letter, p. 6
  11. References
    1. (2000) Circulation, 102(Suppl I):86-9
      1. http://www.circulationaha.org
    2. Chevalier (2003) J Am Coll Cardiol 41:255
    3. King (2002) Am Fam Physician 66:249

Atrial Fibrillation (C0004238)

Definition (MSH)Abnormal cardiac rhythm that is characterized by rapid, uncoordinated firing of electrical impulses in the upper chambers of the heart (HEART ATRIA). In such case, blood cannot be effectively pumped into the lower chambers of the heart (HEART VENTRICLES). It is caused by abnormal impulse generation.
Definition (CSP)disorder of cardiac rhythm characterized by rapid, irregular atrial impulses and ineffective atrial contractions.
Definition (NCI)An arrhythmia in which minute areas of the atrial myocardium are in various uncoordinated stages of depolarization and repolarization; instead of intermittently contracting, the atria quiver continuously in a chaotic pattern, causing a totally irregular, often rapid ventricular rate.
Definition (NCI)A supraventricular arrhythmia characterized by uncoordinated atrial myocardium activation due to multiple reentry circuits with consequent deterioration of atrial mechanical function. Instead of intermittently contracting, the atria quiver continuously in a chaotic pattern, causing a totally irregular, often tachycardia ventricular rate. On the ECG it is described by the replacement of consistent P waves by rapid oscillations or fibrillatory waves that vary in size, shape, and timing, associated with an irregular, frequently rapid ventricular response when atrioventricular conduction is intact.
ConceptsPathologic Function (T046)
ICD9427.31
MSHD001281
EnglishAF, AF - Atrial fibrillation, AFib, Atrial Fibrillation, Atrial Fibrillations, Auricular Fibrillation, Auricular Fibrillations, Fibrillation - atrial, FIBRILLATION ATRIAL
Spanishfibrilacion auricular
Parent ConceptsFibrillation (C0232197), cardiac arrhythmia (C0003811), Atrial fibrillation and flutter NOS (C0155709), Supraventricular arrhythmia (C0428974), Atrial arrhythmia (C0085611)
SourcesAOD, CCS, COSTAR, CSP, CST, DXP, ICD9CM, LCH, MEDLINEPLUS, MSH, MTH, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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