II. Indications: Cardioversion

  1. Acute onset of Atrial Fibrillation within prior 48 hours

III. Contraindications: Cardioversion

  1. Hemodynamically unstable (immediate cardioversion indication)
    1. Acute Congestive Heart Failure
    2. Hypotension
    3. Myocardial Ischemia
  2. Unclear Atrial Fibrillation onset (anticoagulate, no cardioversion and follow-up as below)
    1. Cannot confirm Atrial Fibrillation onset <48 hours

IV. Protocol: Step 1 - Rate Control (optional)

  1. Indications
    1. Symptomatic Tachycardia or
    2. Not planning cardioversion and Heart Rate >110
  2. Medications
    1. Diltiazem 0.25 mg/kg over 10 min (may repeat at 0.35 mg/kg)
    2. Metoprolol 5 mg IV every 15 min as needed (typically up to 3 doses)

V. Protocol: Step 2 - Chemical Cardioversion with Procainamide

  1. Indications
    1. Hemodynamically stable with systolic Blood Pressure >100 mmHg
    2. No contraindications (see above)
    3. Normal Serum Potassium and Serum Magnesium
  2. Method
    1. Procainamide 1 g IV over 60 minutes
    2. Monitor with frequent Blood Pressures, and hold Procainamide if systolic Blood Pressure <100 mmHg
    3. Monitor telemetry for arrhythmia, QTc Prolongation, QRS Widening and for successful cardioversion

VI. Protocol: Step 3 - Electrical Cardioversion

  1. Indications
    1. Atrial Fibrillation <48 hours AND
    2. Unstable patient or failed chemical cardioversion (see Procainamide protocol above)
  2. Method
    1. In a stable patient, 6 hours NPO is preferred
    2. Procedural Sedation and Analgesia (e.g. Fentanyl and Propofol)
    3. Apply pads in anterior to posterior position
    4. Synchronized electrical cardioversion starting at 150 to 200 J

VII. Protocol: Step 4a - Cardioversion not attempted (e.g. contraindicated) or unsuccessful

  1. Achieve rate control with Metoprolol or Diltiazem, and discharge home on oral rate control
  2. Start Anticoagulation with Warfarin (INR first, Anticoagulation clinic follow-up) or with DOAC
  3. Outpatient follow-up with Echocardiogram and cardiology at 4 weeks for elective cardioversion

VIII. Protocol: Step 4b - Cardioversion Successful

  1. Anticoagulation (Warfarin or DOAC) indications
    1. Electrical cardioversion
    2. CHADS2-VASc Score >1
  2. Rate control agent (Metoprolol, Diltiazem) indications
    1. Continue if already taking
    2. Consider for paroxysmal Atrial Fibrillation

IX. Efficacy

  1. Study of 660 patients with acute Atrial Fibrillation
    1. Procainamide cardioversion successful in 58% of cases
    2. Electrical cardioversion successful in 91% of cases
    3. Stiell (2010) CJEM 12(3):181-91 +PMID:20522282 [PubMed]

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