Highlights & Basics
- New-onset atrial fibrillation (AF) is a new or first detectable episode of a chaotic and irregular atrial arrhythmia. Prevalence increases progressively with age.
- AF causes significant morbidity and mortality including palpitations, dyspnea, angina, dizziness or syncope, and features of congestive heart failure, tachycardia-induced cardiomyopathy, stroke, and death.
- ECG shows absent P waves, presence of fibrillatory waves, and irregularly irregular QRS complexes.
- Most patients presenting with new-onset or "acute" atrial fibrillation (AF) do not require immediate cardioversion. Most patients will require medical therapy to control ventricular rate.
- Patients who develop hemodynamic compromise should have immediate direct current cardioversion.
- If the precise timing of the onset of AF is unclear, a transesophageal echocardiogram must be performed to exclude left atrial clots before cardioversion.
Quick Reference
History & Exam
Key Factors
irregular pulse rate
Other Factors
palpitations
hypotension
elevated jugular venous pressure
added heart sounds
dizziness
dyspnea
rales
evidence of stroke
Diagnostics Tests
1st Tests to Order
ECG
serum electrolytes
cardiac biomarkers
thyroid function tests
CXR
transthoracic echocardiogram
transesophageal echocardiogram (TEE)
Other Tests to consider
electrophysiologic study
exercise stress tests
Treatment Options
presumptive
hemodynamically unstable
DC cardioversion
acute
hemodynamically stable with left atrial thrombus, or presence of thrombus unknown/duration of AF unknown
without heart failure
with heart failure
Definition
Classifications
Classification and definition of AF subtypes
- Paroxysmal AF: AF that is recurrent (>1 episode ≥30 seconds in duration) and that terminates spontaneously or with intervention within 7 days.
- Persistent AF: AF that is continuously sustained beyond 7 days, including episodes terminated by cardioversion after 7 days or longer.
- Long-standing persistent AF: a subgroup of persistent AF, that is continuous for >1 year.
- Permanent AF: AF that is refractory to cardioversion and sinus rhythm cannot be restored or maintained, such that AF is accepted as a final rhythm. A decision has been made by the patient and physician not to pursue restoration of sinus rhythm by any means, including catheter or surgical ablation.
- Nonvalvular AF: AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair. The terms valvular/nonvalvular differentiate patients with AF in the presence/absence of moderate or severe mitral stenosis or a prosthetic heart valve. The European Society of Cardiology advises that this terminology may be confusing and should be avoided.[2]
- Lone AF: the term "lone AF" applies to patients ages <60 years without echocardiographic or clinical evidence of cardiac, pulmonary, or circulatory disease. However, because definitions are variable, and all patients with AF have some form of pathophysiologic basis, the term "lone AF" is potentially confusing and should not be used.
- Chronic AF: has variable definitions. For more information on chronic AF see Chronic atrial fibrillation .
- Subclinical AF: the term subclinical AF usually represents asymptomatic episodes of AF detected either by cardiac implantable electronic devices or by cardiac monitors.
Vignette
Common Vignette 1
Common Vignette 2
Epidemiology
Etiology
Pathophysiology
Images
Multiple wavelets of atrial fibrillation compete with each other in the atrium and bombard the atrioventricular node with many signals
Atrial fibrillation
Atrial flutter
Multifocal atrial tachycardia
Transesophageal echocardiogram showing left atrial appendage clot. LA=left atrium; LAA=left atrial appendage; LV=left ventricle
Atrial fibrillation
Atrial fibrillation with Wolff-Parkinson-White syndrome
CHA2DS2-VASc (congestive heart failure/left ventricular dysfunction, hypertension, age ≥75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65-74 years, sex category [female])
Diagnostic Approach
History and examination
ECG
Investigation for causal factors
Risk Factors
History & Exam
Tests
Differential Diagnosis
Atrial flutter
Differentiating Signs/Symptoms
- Clinical history and physical exam may not be useful to differentiate from AF.
Differentiating Tests
- ECG shows absence of P waves, presence of characteristic flutter waves that give typical saw-tooth appearance in the inferior limb leads, and QRS complexes that are regularly (typically 2:1, 3:1, 4:1) irregular.Image
Wolff-Parkinson-White syndrome
Differentiating Signs/Symptoms
- Usually presents at younger age (teens or early 20s).
- Often precipitated by exercise.
Differentiating Tests
- Classic ECG has shortened PR interval and delta wave on the QRS complex, which may degenerate into AF.Image
- An electrophysiologic study with view to curative ablation procedure is suggested for patients with ECG changes suggestive of Wolff-Parkinson-White syndrome who present with AF and rapid ventricular rate.
Differentiating Signs/Symptoms
- Clinical history and physical exam may not be useful to differentiate from AF. However, atrial tachycardia (in particular, multifocal atrial tachycardia) is more common in patients with severe COPD.
Differentiating Tests
- ECG shows abnormal P waves. In multifocal atrial tachycardia, there are at least 3 different morphologies of P waves.Image
Differentiating Signs/Symptoms
- Clinical history and physical exam may not be useful to differentiate from AF.
Differentiating Tests
- ECG shows underlying normal sinus rhythm, with additional, randomly occurring, ventricular or atrial ectopic complexes.
Criteria
- History of stroke, transient ischemic attack, or thromboembolism
- Age ≥75 years
- Age 65-74 years
- History of hypertension, diabetes, congestive heart failure, or vascular disease (myocardial infarction, complex aortic plaque, peripheral arterial disease)
- Female
- Female sex
- Age 65-74 years
- Coronary artery disease
- Thyrotoxicosis.
- Age ≥75 years
- Hypertension
- Heart failure
- Left ventricular ejection fraction ≤35%
- Diabetes mellitus.
- Previous stroke, transient ischemic attack, or embolism
- Mitral stenosis
- Prosthetic heart valve.
Screening
Treatment Approach
- Ventricular rate control
- Restoration and maintenance of sinus rhythm
- Prevention of thromboembolic events.
- The GARFIELD-AF study: a prospective registry of more than 52,000 patients with newly diagnosed AF. Data from GARFIELD-AF suggest that DOACs are associated with lower risks of all-cause death and bleeding than vitamin K antagonists such as warfarin.[120]
- The RE-LY trial: compared dabigatran, an oral direct thrombin inhibitor, with warfarin. The trial included 18,113 patients and had a median follow-up of 2 years.[101] The results of RE-LY suggest that compared with warfarin, dabigatran showed noninferiority at a low dose, and superiority at a high dose regarding rates of stroke and systemic embolism (warfarin 1.69% per year, lower-dose dabigatran 1.53% per year, and higher-dose dabigatran 1.11% per year for primary end point of stroke and systemic embolism). Adverse bleeding event rates were lower with a lower dose and similar with a higher dose of dabigatran compared with warfarin. The rate of myocardial infarction was higher with both doses of dabigatran than with warfarin.[101] [115][121]
- The ROCKET AF, ARISTOTLE, and ENGAGE-AF trials: the oral direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban were compared with warfarin for stroke prevention in patients with nonvalvular AF in the ROCKET AF (14,264 patients, median follow-up of 1.9 years), ARISTOTLE (18,201 patients, median follow-up of 1.8 years), and the ENGAGE-AF (21,105 patients, median follow-up of 2.8 years) trials, respectively.[122] [123] [124] [125] The primary end point of stroke and/or systemic embolism were 1.7% per year with rivaroxaban compared with 2.2% per year with warfarin in the ROCKET AF trial, 1.3% per year with apixaban compared with 1.6% per year with warfarin in the ARISTOTLE trial, and 1.6% per year with a lower dose and 1.2% per year with a higher dose of edoxaban compared with 1.5% per year with warfarin in the ENGAGE-AF trial.[122] [123] [124] [125]
- One prospective cohort study comparing rivaroxaban to vitamin K antagonists for bleeding risk in patients over 80 years of age, with nonvalvular AF: the primary end point of major bleeding occurred in 6.5% of patients treated with rivaroxaban and 11.2% treated with vitamin K antagonists.[126] Fatal bleeding occurred in 0.9% of rivaroxaban patients and 3.3% of patients treated with vitamin K antagonists.[126]
- Whether the patient is hemodynamically stable or unstable
- If hemodynamically stable, whether the patient is symptomatic or asymptomatic
- If symptomatic, the onset of the symptoms (<48 hours, ≥48 hours, or unknown)
- The presence of associated heart failure
- The presence of a thrombus on TEE
- If a thrombus is absent on TEE, thromboembolic risk is stratified.
Need for hospital admission
- Patients with underlying heart disease who have hemodynamic consequences or symptoms of angina, heart failure, or syncope or who are at risk for a complication resulting from therapy of the arrhythmia
- Older patients
- Associated or precipitant medical conditions that require further treatment, such as heart failure, pulmonary problems (e.g., pneumonia, pulmonary embolism), hypertension, or hyperthyroidism.
Hemodynamically unstable AF
Hemodynamically stable AF: symptomatic
- If CHA2DS2-VASc score is 0-1, no anticoagulation is required.
- If CHA2DS2-VASc score is ≥2, intravenous heparin (aPTT of 45-60 seconds) or subcutaneous low molecular weight heparin should be started before cardioversion. Once sinus rhythm is restored, the patient should preferably be started on a DOAC (dabigatran, rivaroxaban, apixaban, and edoxaban), unless they are not eligible for a DOAC (e.g., presence of moderate-to-severe mitral valve stenosis or mechanical prosthetic valves), or DOACs are unavailable. After the heparin is stopped, the first dose of the DOAC is usually given at the next scheduled dose time; however, local guidance should be consulted for each DOAC. If not using DOACs, start warfarin, and continue heparin until the warfarin levels are therapeutic (INR 2-3).[98]
- DOACs should not be used in patients with mechanical prosthetic valves. The concomitant use of DOACs with heparin (including low molecular weight heparin), heparin derivatives, or warfarin is contraindicated. DOACs should be used with caution in patients with renal impairment; consult prescribing information for specific guidance.
- If CHA2DS2-VASc score is 0-1, heparin should be started, and cardioversion should be delayed until the patient is established on heparin with a target aPTT of 45-60 seconds. Following successful cardioversion, heparin can be discontinued. The decision to administer aspirin for long-term therapy in these patients should be individualized and discussed with the patient, as no major consensus exists for those with a CHADS2 score of 1 or a CHA2DS2-VASc score of 1 due to sex risk (i.e., female patients).[1] [18] [41][144] [145] [146] American Heart Association 2014 guidelines include aspirin as an option in this circumstance, while the UK National Institute for Health and Care Excellence does not recommend aspirin, and the European Society of Cardiology actively advises against the use of aspirin in this group, in the absence of coexisting coronary artery disease.[1] [2] [18] [147] There is currently no evidence to support longer-term anticoagulation in patients with a score of 1 or lower. However, therapeutic decisions should be based on an individual assessment of thromboembolic versus bleeding risk; long-term anticoagulation is always required for patients with any form of cancer, irrespective of CHA2DS2-VASc score, even after sinus rhythm has been restored.[1] [147] [148] [149] [150] If the decision is made to continue long-term anticoagulation in patients with a CHA2DS2-VASc score of 1, DOACs have a superior net benefit compared with vitamin K antagonists.[147] [148]
- If CHA2DS2-VASc score is ≥2, all eligible patients should preferably be started on a DOAC (dabigatran, rivaroxaban, apixaban, and edoxaban).[98] In DOAC-ineligible patients, start concomitant heparin and warfarin therapy, and continue heparin until the warfarin levels are therapeutic (INR 2-3).[1] [28] Anticoagulation with warfarin at the target INR should be established for 3-4 weeks before cardioversion is attempted.[28] DOACs should not be used in patients with mechanical prosthetic valves. The concomitant use of DOACs with heparin (including low molecular weight heparin), heparin derivatives, or warfarin is contraindicated. DOACs should be used with caution in patients with renal impairment; consult prescribing information for specific guidance.
Hemodynamically stable AF: asymptomatic
Postcardioversion management
- Patients with a newly detected first episode of new-onset AF converted to sinus rhythm are not continued on rhythm maintenance therapy, as the risks outweigh the benefits.
- Therapeutic decisions should always be based on an individual assessment of thromboembolic versus bleeding risk.
- Long-term anticoagulation is required for patients with identified high risk for thromboembolism (CHA2DS2-VASc score ≥1 in patients with nonvalvular AF, those with valvular AF, with prosthetic mitral valve, patients with hypertrophic cardiomyopathy; any form of cancer irrespective of CHA2DS2-VASc score), even after sinus rhythm has been restored.[1] [142] [147] [148] [149]
Treatment Options
hemodynamically unstable
DC cardioversion
Comments
- Used immediately if the patient is hemodynamically unstable with chest pain, shortness of breath, dizziness or syncope, hypotension, and rapid heart rate.
- Direct current (DC) cardioversion is performed under adequate short-acting general anesthesia and involves delivery of an electrical shock synchronized with the intrinsic activity of the heart by sensing the R wave of the ECG (i.e., synchronized). The energy output for successful termination of new-onset AF varies from 200 J to a maximum of 400 J depending on the body size and the presence of other comorbid conditions. Lower energy of 100 J may be used as the starting level when biphasic energy is used.
- For patients with hemodynamically unstable AF, initiation of anticoagulation should not delay DC cardioversion. It is reasonable to consider administering intravenous bolus of unfractionated heparin followed by infusion, or low molecular weight heparin or direct-acting oral anticoagulant and to continue this after cardioversion unless contraindicated.[1]
hemodynamically stable with left atrial thrombus, or presence of thrombus unknown/duration of AF unknown
without heart failure
rate control with beta-blocker and/or calcium-channel blocker
Primary Options
- esmolol
500 micrograms/kg intravenously as a loading dose, followed by 50 micrograms/kg/min infusion for 4 minutes, if no response after 5 minutes, repeat loading dose and increase infusion, consult specialist for further guidance on dose
- esmolol
- metoprolol tartrate
2.5 to 5 mg intravenous bolus initially, may repeat every 5 minutes to a total of 3 doses; 25-200 mg orally (regular-release) twice daily
- metoprolol tartrate
- propranolol hydrochloride
1 mg intravenously initially, may repeat every 2 minutes to a total of 3 doses; 10-40 mg orally (immediate-release) three to four times daily
- propranolol hydrochloride
- atenolol
25-100 mg orally once daily
- atenolol
- nadolol
10-240 mg orally once daily
- nadolol
- bisoprolol
2.5 to 10 mg orally once daily
- bisoprolol
- carvedilol
3.125 to 25 mg orally twice daily
- carvedilol
- diltiazem
0.25 mg/kg intravenous bolus initially, may give a second bolus of 0.35 mg/kg after 15 minutes if necessary, followed by 5-15 mg/hour infusion; 120-360 mg/day orally (regular-release) given in 3-4 divided doses
- diltiazem
- verapamil
5-10 mg intravenous bolus initially, may give a second bolus of 10 mg after 30 minutes if necessary, followed by a 0.005 mg/kg/minute infusion; 240-320 mg/day orally (regular-release) given in 3-4 divided doses; 180-480 mg orally (extended-release) once daily
- verapamil
Comments
- Rate-control therapy is required until cardioversion is successful.
- Beta-blockers and calcium-channel blockers (CCBs) slow atrioventricular nodal conduction of cardiac impulses and subsequently reduce ventricular rate.
- Intravenous administration of beta-blockers or calcium-channel blockers may be necessary for rapid control of ventricular rate. Furthermore, in the event of hemodynamic adverse effects, the infusion may be discontinued promptly.
- Beta-blockers are particularly useful when new-onset AF is associated with an acute myocardial infarction or angina, and when new-onset AF is precipitated after exercise.
- Esmolol is useful in patients at risk of complications from beta-blockade, particularly those with reactive airway disease, left ventricular dysfunction, and/or peripheral vascular disease.
- CCBs are preferred in patients with chronic lung disease where bronchospasm may occur with beta-blockers.
- Both groups of medications may cause severe bradycardia, heart block, asystole, heart failure, or hypotension.
- If rate control is inadequate with monotherapy, a combination of a beta-blocker and CCB may be used. In addition, identification and treatment of any potential triggers of new-onset AF is very important, because rate and rhythm control measures are less likely to succeed if the acute precipitant persists.[41]
anticoagulation
Primary Options
- dabigatran etexilate
150 mg orally twice daily
- dabigatran etexilate
- apixaban
2.5 to 5 mg orally twice daily
- apixaban
- edoxaban
60 mg orally once daily
- edoxaban
- rivaroxaban
20 mg orally once daily
- rivaroxaban
- heparin
see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds
or
- enoxaparin
1 mg/kg subcutaneously every 12 hours
AND
- warfarin
2-5 mg orally once daily initially, adjust dose according to target INR
- heparin
Comments
- Anticoagulation is recommended in all patients with AF due to the high risk of thromboembolic events. The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, apixaban, or edoxaban. DOACs are approved for stroke prevention and have a more favorable side-effect profile than vitamin K antagonists in patients with nonvalvular AF.
- All eligible patients should be started on a DOAC.[98]
- DOACs should be used with caution in patients with renal impairment. If a DOAC is suitable, depending on the degree of renal impairment and the indication for use, a dose adjustment may be required. Consult the prescribing information for specific guidance on use in patients with renal impairment.
- DOACs should not be used in patients with mechanical prosthetic valves or moderate-to-severe mitral stenosis, due to an increased risk of stroke, heart attack, and blood clot in these patients, nor should they be used in combination with heparin (including low molecular weight heparin), heparin derivatives, or warfarin.[110] Patients with diabetes are at risk of complications of diabetes when treated with oral anticoagulants; this risk seems to be lower with DOACs compared with vitamin K antagonists. Dabigatran is favored for its efficacy and lower rates of adverse effects in this patient group.[133] [134]
- In DOAC-ineligible patients, start concomitant heparin and warfarin therapy, and continue heparin until the warfarin levels are therapeutic (INR 2-3). Anticoagulation with warfarin at the target INR should be established for 3-4 weeks before cardioversion is attempted.
electrical or pharmacologic cardioversion following 3-4 weeks of anticoagulation
Primary Options
- flecainide
200-300 mg orally as a single dose
- flecainide
- propafenone
600 mg orally as a single dose
- propafenone
- amiodarone
150 mg intravenously initially over 10 minutes, followed by 1 mg/min infusion for 6 hours, and then 0.5 mg/min infusion for 18 hours; 600-800 mg/day orally given in 2-3 divided doses up to a total loading dose of up to 10 g, followed by 200 mg orally once daily
- amiodarone
- dronedarone
400 mg orally twice daily
- dronedarone
- ibutilide
0.01 mg/kg (maximum 1 mg/dose) intravenously initially, may repeat 10 minutes after initial dose if no response
- ibutilide
Comments
- Cardioversion should only be attempted once the patient has been established on anticoagulation with a target INR of 2 to 3 for 3-4 weeks, and following a repeat transesophageal echocardiogram (TEE), if available, to confirm left atrial thrombus. If TEE cannot be performed, the patient should be treated as for presumed thrombus and recommendations for confirmed left atrial thrombus should be followed.Image
- DC cardioversion is fast, safe, and efficient.
- Class IC agents (flecainide, propafenone) have a higher mortality in patients with coronary artery disease (CAD) and are contraindicated in patients with CAD and cardiac dysfunction. AF may convert to atrial flutter that may conduct with rapid ventricular rate.
- Flecainide has strong evidence of efficacy for pharmacologic conversion (odds ratio [OR] 24.7, 95% CI 9.0 to 68.3). High conversion rate of about 70% at 3 hours after treatment and up to 90% at 8 hours.[151]
- Propafenone also has strong evidence of efficacy for pharmacologic conversion (OR 4.6, 95% CI 2.6 to 8.2). High conversion rates of up to 76% at 8 hours after treatment.[151]
- Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents in conversion to sinus rhythm.
- Dronedarone is a multichannel blocker and has noncompetitive anti-adrenergic activity.[106] [107] [108] It is less effective than amiodarone but has fewer side effects. Although not used primarily for cardioversion, it may be used for maintenance of cardioversion after successful cardioversion in clinically stable adult patients with paroxysmal or persistent AF and associated cardiovascular risk factors. It is contraindicated in patients with New York Heart Association (NYHA) class IV heart failure or NYHA class II or III heart failure with a recent (within the previous 4 weeks) decompensation requiring hospitalization or referral to a specialized heart failure clinic, and in patients with permanent AF.[135] [136]
- Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Up to 70% of all conversions occur within 20 minutes of infusion. It has strong evidence of efficacy for pharmacologic conversion (OR 29.1, 95% CI 9.8 to 86.1). Conversion rates are between 33% and 45% within the first 70 minutes. Because the half-life of ibutilide is 3-6 hours, a prolonged observation period is recommended in patients who have received ibutilide.[151]
with heart failure
rate control with beta-blocker, digoxin, or amiodarone
Primary Options
- carvedilol
3.125 to 25 mg orally twice daily
- carvedilol
- metoprolol tartrate
2.5 to 5 mg intravenous bolus initially, may repeat every 5 minutes to a total of 3 doses; 25-200 mg orally (regular-release) twice daily
- metoprolol tartrate
- bisoprolol
2.5 to 10 mg orally once daily
- bisoprolol
- digoxin
0.75 to 1.5 mg orally as a loading dose given in divided doses on first day, followed by maintenance dose of 0.125 to 0.5 mg once daily
- digoxin
- amiodarone
300 mg intravenously initially over 1 hour, followed by 10-50 mg/hour infusion for 24 hours, and then 100-200 mg orally once daily
- amiodarone
Comments
- Choice of pharmacologic agent/s in patients with heart failure is dictated by the degree of heart failure and type of heart failure (i.e., reduced or preserved ejection fraction [EF]). Drugs that potentially accentuate cardiac contractility are therefore avoided. Thus, calcium-channel blockers, which may be used in heart failure (HF) with preserved EF, are not recommended in patients with reduced EF (heart failure with reduced ejection fraction [HFrEF]). Beta-blockers such as carvedilol, metoprolol, and bisoprolol that are recommended for HF in patients with reduced and preserved EF may be used for rate control as well.
- Digoxin is not considered a first-line agent for the purpose of rate control, but it can be useful in patients with heart failure. One study explored whether digoxin use was independently associated with increased mortality in patients with AF; compared with propensity score-matched control participants, the risk of death and sudden death was significantly higher in new digoxin users.[103] In patients with AF taking digoxin, the risk of death was independently related to serum digoxin concentration and was highest in patients with concentrations of ≥1.2 ng/mL (≥1.54 nmol/L).[103]
- In addition, identification and treatment of any potential triggers of new-onset AF is very important, because rate and rhythm control measures are less likely to succeed if the acute precipitant persists.[41]
anticoagulation
Primary Options
- dabigatran etexilate
150 mg orally twice daily
- dabigatran etexilate
- apixaban
2.5 to 5 mg orally twice daily
- apixaban
- edoxaban
60 mg orally once daily
- edoxaban
- rivaroxaban
20 mg orally once daily
- rivaroxaban
- heparin
see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds
or
- enoxaparin
1 mg/kg subcutaneously every 12 hours
AND
- warfarin
2-5 mg orally once daily initially, adjust dose according to target INR
- heparin
Comments
- Anticoagulation is recommended in all patients with AF due to the high risk of thromboembolic events. The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, apixaban, or edoxaban. DOACs are approved for stroke prevention and have a more favorable side-effect profile than vitamin K antagonists in patients with nonvalvular AF.
- All eligible patients should be started on a DOAC.[98]
- DOACs should be used with caution in patients with renal impairment. If a DOAC is suitable, depending on the degree of renal impairment and the indication for use, a dose adjustment may be required. Consult the prescribing information for specific guidance on use in patients with renal impairment.
- DOACs should not be used in patients with mechanical prosthetic valves or moderate-to-severe mitral stenosis, due to an increased risk of stroke, heart attack, and blood clot in these patients, nor should they be used in combination with heparin (including low molecular weight heparin), heparin derivatives, or warfarin.[110]
- In DOAC-ineligible patients, start concomitant heparin and warfarin therapy, and continue heparin until the warfarin levels are therapeutic (INR 2-3). Anticoagulation with warfarin at the target INR should be established for 3- 4 weeks before cardioversion is attempted.
electrical or pharmacologic cardioversion following 3-4 weeks of anticoagulation
Primary Options
- amiodarone
150 mg intravenously initially over 10 minutes, followed by 1 mg/min infusion for 6 hours, and then 0.5 mg/min infusion for 18 hours; 600-800 mg/day orally given in 2-3 divided doses up to a total loading dose of up to 10 g, followed by 200 mg orally once daily
- amiodarone
- ibutilide
0.01 mg/kg (maximum 1 mg/dose) intravenously initially, may repeat 10 minutes after initial dose if no response
- ibutilide
Comments
- Cardioversion should only be attempted once the patient has been established on anticoagulation with a target INR of 2 to 3 for 3-4 weeks, and following a repeat transesophageal echocardiogram (TEE), if available, to confirm left atrial thrombus. If TEE cannot be performed, the patient should be treated as for presumed thrombus and recommendations for confirmed left atrial thrombus should be followed.Image
- DC cardioversion is fast, safe, and efficient.
- Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents in conversion to sinus rhythm.
- Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Up to 70% of all conversions occur within 20 minutes of infusion. It has strong evidence of efficacy for pharmacologic conversion (OR 29.1, 95% CI 9.8 to 86.1). Conversion rates are between 33% and 45% within the first 70 minutes. Because the half-life of ibutilide is 3-6 hours, a prolonged observation period is recommended in patients who have received ibutilide.[151]
hemodynamically stable without left atrial thrombus: symptom onset <48 hours
without heart failure: CHA2DS2-VASc score 0-1
rate control with beta-blocker and/or calcium-channel blocker
Primary Options
- esmolol
500 micrograms/kg intravenously as a loading dose, followed by 50 micrograms/kg/min infusion for 4 minutes, if no response after 5 minutes, repeat loading dose and increase infusion, consult specialist for further guidance on dose
- esmolol
- metoprolol tartrate
2.5 to 5 mg intravenous bolus initially, may repeat every 5 minutes to a total of 3 doses; 25-200 mg orally (regular-release) twice daily
- metoprolol tartrate
- propranolol hydrochloride
1 mg intravenously initially, may repeat every 2 minutes to a total of 3 doses; 10-40 mg orally (immediate-release) three to four times daily
- propranolol hydrochloride
- atenolol
25-100 mg orally once daily
- atenolol
- nadolol
10-240 mg orally once daily
- nadolol
- bisoprolol
2.5 to 10 mg orally once daily
- bisoprolol
- carvedilol
3.125 to 25 mg orally twice daily
- carvedilol
- diltiazem
0.25 mg/kg intravenous bolus initially, may give a second bolus of 0.35 mg/kg after 15 minutes if necessary, followed by 5-15 mg/hour infusion; 120-360 mg/day orally (regular-release) given in 3-4 divided doses
- diltiazem
- verapamil
5-10 mg intravenous bolus initially, may give a second bolus of 10 mg after 30 minutes if necessary, followed by a 0.005 mg/kg/minute infusion; 240-320 mg/day orally (regular-release) given in 3-4 divided doses; 180-480 mg orally (extended-release) once daily
- verapamil
Comments
- Rate-control therapy is required until cardioversion is successful.
- Intravenous administration of beta-blockers or calcium-channel blockers (CCBs) may be necessary for rapid control of ventricular rate. Furthermore, in the event of hemodynamic adverse effects, the infusion may be discontinued promptly.
- Beta-blockers and CCBs slow atrioventricular nodal conduction of cardiac impulses and subsequently reduce ventricular rate.
- Beta-blockers are particularly useful when new-onset AF is associated with an acute myocardial infarction or angina, and when new-onset AF is precipitated after exercise.
- Esmolol is useful in patients at risk of complications from beta-blockade, particularly those with reactive airway disease, left ventricular dysfunction, and/or peripheral vascular disease.
- CCBs are preferred in patients with chronic lung disease where bronchospasm may occur with beta-blockers.
- Both groups of medications may cause severe bradycardia, heart block, asystole, heart failure, or hypotension.
- If rate control is inadequate with monotherapy, a combination of a beta-blocker and CCB may be used. In addition, identification and treatment of any potential triggers of new-onset AF is very important, because rate and rhythm control measures are less likely to succeed if the acute precipitant persists.[41]
electrical or pharmacologic cardioversion
Primary Options
- flecainide
200-300 mg orally as a single dose
- flecainide
- propafenone
600 mg orally as a single dose
- propafenone
- amiodarone
150 mg intravenously initially over 10 minutes, followed by 1 mg/min infusion for 6 hours, and then 0.5 mg/min infusion for 18 hours; 600-800 mg/day orally given in 2-3 divided doses up to a total loading dose of up to 10 g, followed by 200 mg orally once daily
- amiodarone
- dronedarone
400 mg orally twice daily
- dronedarone
- ibutilide
0.01 mg/kg (maximum 1 mg/dose) intravenously initially, may repeat 10 minutes after initial dose if no response
- ibutilide
Comments
- Patients with low thromboembolic risk presenting with new-onset AF within 48 hours can undergo immediate cardioversion without the need for anticoagulation. There is no significant difference in terms of outcome between DC and pharmacologic cardioversion. Timing of cardioversion in patients who are hemodynamically stable and minimally symptomatic is a topic of research. Some studies suggest no benefit of early cardioversion over a "wait and see" approach; others suggest outcomes are improved when cardioversion is performed early.[104] [105]
- DC cardioversion is fast, safe, and efficient.
- Class IC agents (flecainide, propafenone) have a higher mortality in patients with coronary artery disease (CAD) and are contraindicated in patients with CAD and cardiac dysfunction. AF may convert to atrial flutter that may conduct with rapid ventricular rate.
- Flecainide has strong evidence of efficacy for pharmacologic conversion (odds ratio [OR] 24.7, 95% CI 9.0 to 68.3). High conversion rate of about 70% at 3 hours after treatment and up to 90% at 8 hours.[151]
- Propafenone also has strong evidence of efficacy for pharmacologic conversion (OR 4.6, 95% CI 2.6 to 8.2). High conversion rates of up to 76% at 8 hours after treatment.[151]
- Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents in conversion to sinus rhythm.
- Dronedarone is a multichannel blocker and has noncompetitive anti-adrenergic activity.[106] [107] [108] It is less effective than amiodarone but has fewer side effects. Although not used primarily for cardioversion, it may be used for maintenance of cardioversion after successful cardioversion in clinically stable adult patients with paroxysmal or persistent AF and associated cardiovascular risk factors. It is contraindicated in patients with New York Heart Association (NYHA) class IV heart failure or NYHA class II or III heart failure with a recent (within the previous 4 weeks) decompensation requiring hospitalization or referral to a specialized heart failure clinic, and in patients with permanent AF.[135] [136]
- Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Up to 70% of all conversions occur within 20 minutes of infusion. It has strong evidence of efficacy for pharmacologic conversion (OR 29.1, 95% CI 9.8 to 86.1). Conversion rates are between 33% and 45% within the first 70 minutes. Because the half-life of ibutilide is 3-6 hours, prolonged observation period is recommended in patients who have received ibutilide.[151]
without heart failure: CHA2DS2-VASc score ≥2
rate control with beta-blocker and/or calcium-channel blocker
Primary Options
- esmolol
500 micrograms/kg intravenously as a loading dose, followed by 50 micrograms/kg/min infusion for 4 minutes, if no response after 5 minutes, repeat loading dose and increase infusion, consult specialist for further guidance on dose
- esmolol
- metoprolol tartrate
2.5 to 5 mg intravenous bolus initially, may repeat every 5 minutes to a total of 3 doses; 25-200 mg orally (regular-release) twice daily
- metoprolol tartrate
- propranolol hydrochloride
1 mg intravenously initially, may repeat every 2 minutes to a total of 3 doses; 10-40 mg orally (immediate-release) three to four times daily
- propranolol hydrochloride
- atenolol
25-100 mg orally once daily
- atenolol
- nadolol
10-240 mg orally once daily
- nadolol
- bisoprolol
2.5 to 10 mg orally once daily
- bisoprolol
- carvedilol
3.125 to 25 mg orally twice daily
- carvedilol
- diltiazem
0.25 mg/kg intravenous bolus initially, may give a second bolus of 0.35 mg/kg after 15 minutes if necessary, followed by 5-15 mg/hour infusion; 120-360 mg/day orally (regular-release) given in 3-4 divided doses
- diltiazem
- verapamil
5-10 mg intravenous bolus initially, may give a second bolus of 10 mg after 30 minutes if necessary, followed by a 0.005 mg/kg/minute infusion; 240-320 mg/day orally (regular-release) given in 3-4 divided doses; 180-480 mg orally (extended-release) once daily
- verapamil
Comments
- Rate-control therapy is required until cardioversion is successful.
- Intravenous administration of beta-blockers or calcium-channel blockers (CCBs) may be necessary for rapid control of ventricular rate. Furthermore, in the event of hemodynamic adverse effects, the infusion may be discontinued promptly.
- Beta-blockers and CCBs slow atrioventricular nodal conduction of cardiac impulses and subsequently reduce ventricular rate.
- Beta-blockers are particularly useful when new-onset AF is associated with an acute myocardial infarction or angina, and when new-onset AF is precipitated after exercise.
- Esmolol is useful in patients at risk of complications from beta-blockade, particularly those with reactive airway disease, left ventricular dysfunction, and/or peripheral vascular disease.
- CCBs are preferred in patients with chronic lung disease where bronchospasm may occur with beta-blockers.
- Both groups of medications may cause severe bradycardia, heart block, asystole, heart failure, or hypotension.
- If rate control is inadequate with monotherapy, a combination of a beta-blocker and CCB may be used. In addition, identification and treatment of any potential triggers of new-onset AF is very important, because rate and rhythm control measures are less likely to succeed if the acute precipitant persists.[41]
electrical or pharmacologic cardioversion + heparin
Primary Options
- flecainide
200-300 mg orally as a single dose
or
- propafenone
600 mg orally as a single dose
or
- amiodarone
150 mg intravenously initially over 10 minutes, followed by 1 mg/min infusion for 6 hours, and then 0.5 mg/min infusion for 18 hours; 600-800 mg/day orally given in 2-3 divided doses up to a total loading dose of up to 10 g, followed by 200 mg orally once daily
or
- dronedarone
400 mg orally twice daily
or
- ibutilide
0.01 mg/kg (maximum 1 mg/dose) intravenously initially, may repeat 10 minutes after initial dose if no response
AND
- heparin
see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds
or
- enoxaparin
1 mg/kg subcutaneously every 12 hours
- flecainide
Comments
- Intravenous heparin (activated partial thromboplastin time [aPTT] of 45-60 seconds) or subcutaneous low molecular weight heparin should be started before cardioversion. There is no significant difference in terms of outcome between DC and pharmacologic cardioversion. Timing of cardioversion in patients who are hemodynamically stable and minimally symptomatic is a topic of research. Some studies suggest no benefit of early cardioversion over a "wait and see" approach; others suggest outcomes are improved when cardioversion is performed early.[104] [105]
- DC cardioversion is fast, safe, and efficient.
- Class IC agents (flecainide, propafenone) have a higher mortality in patients with coronary artery disease (CAD) and are contraindicated in patients with CAD and cardiac dysfunction. AF may convert to atrial flutter that may conduct with rapid ventricular rate.
- Flecainide has strong evidence of efficacy for pharmacologic conversion (odds ratio [OR] 24.7, 95% CI 9.0 to 68.3). High conversion rate of about 70% at 3 hours after treatment and up to 90% at 8 hours.[151]
- Propafenone also has strong evidence of efficacy for pharmacologic conversion (OR 4.6, 95% CI 2.6 to 8.2). High conversion rates of up to 76% at 8 hours after treatment.[151]
- Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents in conversion to sinus rhythm.
- Dronedarone is a multichannel blocker and has noncompetitive anti-adrenergic activity.[106] [107] [108] It is less effective than amiodarone but has fewer side effects. Although not used primarily for cardioversion, it may be used for maintenance of cardioversion after successful cardioversion in clinically stable adult patients with paroxysmal or persistent AF and associated cardiovascular risk factors. It is contraindicated in patients with New York Heart Association (NYHA) class IV heart failure or NYHA class II or III heart failure with a recent (within the previous 4 weeks) decompensation requiring hospitalization or referral to a specialized heart failure clinic, and in patients with permanent AF.[135] [136]
- Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Up to 70% of all conversions occur within 20 minutes of infusion. It has strong evidence of efficacy for pharmacologic conversion (OR 29.1, 95% CI 9.8 to 86.1). Conversion rates are between 33% and 45% within the first 70 minutes. Because the half-life of ibutilide is 3 to 6 hours, prolonged observation period is recommended in patients who have received ibutilide.[151]
anticoagulation
Primary Options
- dabigatran etexilate
150 mg orally twice daily
- dabigatran etexilate
- apixaban
2.5 to 5 mg orally twice daily
- apixaban
- edoxaban
60 mg orally once daily
- edoxaban
- rivaroxaban
20 mg orally once daily
- rivaroxaban
- warfarin
2-5 mg orally once daily initially, adjust dose according to target INR
- warfarin
Comments
- Anticoagulation is recommended in all patients with AF due to the high risk of thromboembolic events. The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, apixaban, or edoxaban. DOACs are approved for stroke prevention and have a more favorable side-effect profile than vitamin K antagonists in patients with nonvalvular AF.
- All eligible patients should be started on a DOAC.[98]
- DOACs should be used with caution in patients with renal impairment. If a DOAC is suitable, depending on the degree of renal impairment and the indication for use, a dose adjustment may be required. Consult the prescribing information for specific guidance on use in patients with renal impairment.
- DOACs should not be used in patients with mechanical prosthetic valves or moderate-to-severe mitral stenosis, due to an increased risk of stroke, heart attack, and blood clot in these patients, nor should they be used in combination with heparin (including low molecular weight heparin), heparin derivatives, or warfarin.[110]
- In DOAC-ineligible patients, start concomitant heparin and warfarin therapy, and continue heparin until the warfarin levels are therapeutic (INR 2-3). Anticoagulation with warfarin at the target INR should be established for 3-4 weeks before cardioversion is attempted.
with heart failure
rate control with beta-blocker, digoxin, or amiodarone
Primary Options
- carvedilol
3.125 to 25 mg orally twice daily
- carvedilol
- metoprolol tartrate
2.5 to 5 mg intravenous bolus initially, may repeat every 5 minutes to a total of 3 doses; 25-200 mg orally (regular-release) twice daily
- metoprolol tartrate
- bisoprolol
2.5 to 10 mg orally once daily
- bisoprolol
- digoxin
0.75 to 1.5 mg orally as a loading dose given in divided doses on first day, followed by maintenance dose of 0.125 to 0.5 mg once daily
- digoxin
- amiodarone
300 mg intravenously initially over 1 hour, followed by 10-50 mg/hour infusion for 24 hours, and then 100-200 mg orally once daily
- amiodarone
Comments
- Patients with heart failure are considered at high risk of thromboembolism. Additional risk factors may also be present, including age ≥75 years, structural heart disease, diabetes, hypertension, rheumatic heart disease, prosthetic heart valves, or history of prior thromboembolism, and left ventricular ejection fraction is ≤35%.
- Choice of pharmacologic agent/s in patients with heart failure is dictated by the degree of heart failure and type of heart failure (i.e., reduced or preserved ejection fraction [EF]). Drugs that potentially accentuate cardiac contractility are therefore avoided. Thus, calcium-channel blockers, which may be used in heart failure (HF) with preserved EF, are not recommended in patients with reduced EF (heart failure with reduced ejection fraction [HFrEF]). Beta-blockers such as carvedilol, metoprolol, and bisoprolol that are recommended for HF in patients with reduced and preserved EF may be used for rate control as well.
- Digoxin is not considered a first-line agent for the purpose of rate control, but it can be useful in patients with heart failure. One study explored whether digoxin use was independently associated with increased mortality in patients with AF; compared with propensity score-matched control participants, the risk of death and sudden death was significantly higher in new digoxin users.[103] In patients with AF taking digoxin, the risk of death was independently related to serum digoxin concentration and was highest in patients with concentrations of ≥1.2 ng/mL (≥1.54 nmol/L).[103]
- In addition, identification and treatment of any potential triggers of new-onset AF is very important, because rate and rhythm control measures are less likely to succeed if the acute precipitant persists.[41]
electrical or pharmacologic cardioversion + heparin
Primary Options
- amiodarone
150 mg intravenously initially over 10 minutes, followed by 1 mg/min infusion for 6 hours, and then 0.5 mg/min infusion for 18 hours; 600-800 mg/day orally given in 2-3 divided doses up to a total loading dose of up to 10 g, followed by 200 mg orally once daily
or
- ibutilide
0.01 mg/kg (maximum 1 mg/dose) intravenously initially, may repeat 10 minutes after initial dose if no response
AND
- heparin
see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds
or
- enoxaparin
1 mg/kg subcutaneously every 12 hours
- amiodarone
Comments
- Intravenous heparin (activated partial thromboplastin time [aPTT] of 45-60 seconds) or subcutaneous low molecular weight heparin should be started before cardioversion. There is no significant difference in terms of outcome between DC and pharmacologic cardioversion. Timing of cardioversion in patients who are hemodynamically stable and minimally symptomatic is a topic of research. Some studies suggest no benefit of early cardioversion over a "wait and see" approach; others suggest outcomes are improved when cardioversion is performed early.[104] [105]
- DC cardioversion is fast, safe, and efficient.
- Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents in conversion to sinus rhythm.
- Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Up to 70% of all conversions occur within 20 minutes of infusion. It has strong evidence of efficacy for pharmacologic conversion (OR 29.1, 95% CI 9.8 to 86.1). Conversion rates are between 33% and 45% within the first 70 minutes. Because the half-life of ibutilide is 3-6 hours, prolonged observation period is recommended in patients who have received ibutilide.[151]
anticoagulation
Primary Options
- dabigatran etexilate
150 mg orally twice daily
- dabigatran etexilate
- apixaban
2.5 to 5 mg orally twice daily
- apixaban
- edoxaban
60 mg orally once daily
- edoxaban
- rivaroxaban
20 mg orally once daily
- rivaroxaban
- warfarin
2-5 mg orally once daily initially, adjust dose according to target INR
- warfarin
Comments
- Anticoagulation is recommended in all patients with AF due to the high risk of thromboembolic events. The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, apixaban, or edoxaban. DOACs are approved for stroke prevention and have a more favorable side-effect profile than vitamin K antagonists in patients with nonvalvular AF.
- All eligible patients should be started on a DOAC.[98]
- DOACs should be used with caution in patients with renal impairment. If a DOAC is suitable, depending on the degree of renal impairment and the indication for use, a dose adjustment may be required. Consult the prescribing information for specific guidance on use in patients with renal impairment.
- DOACs should not be used in patients with mechanical prosthetic valves or moderate-to-severe mitral stenosis, due to an increased risk of stroke, heart attack, and blood clot in these patients, nor should they be used in combination with heparin (including low molecular weight heparin), heparin derivatives, or warfarin.[110]
- In DOAC-ineligible patients, start concomitant heparin and warfarin therapy, and continue heparin until the warfarin levels are therapeutic (INR 2-3). Anticoagulation with warfarin at the target INR should be established for 3-4 weeks before cardioversion is attempted.
hemodynamically stable without left atrial thrombus: symptom onset ≥48 hours
without heart failure: CHA2DS2-VASc score 0-1
rate control with beta-blocker and/or calcium-channel blocker
Primary Options
- esmolol
500 micrograms/kg intravenously as a loading dose, followed by 50 micrograms/kg/min infusion for 4 minutes, if no response after 5 minutes, repeat loading dose and increase infusion, consult specialist for further guidance on dose
- esmolol
- metoprolol tartrate
2.5 to 5 mg intravenous bolus initially, may repeat every 5 minutes to a total of 3 doses; 25-200 mg orally (regular-release) twice daily
- metoprolol tartrate
- propranolol hydrochloride
1 mg intravenously initially, may repeat every 2 minutes to a total of 3 doses; 10-40 mg orally (immediate-release) three to four times daily
- propranolol hydrochloride
- atenolol
25-100 mg orally once daily
- atenolol
- nadolol
10-240 mg orally once daily
- nadolol
- bisoprolol
2.5 to 10 mg orally once daily
- bisoprolol
- carvedilol
3.125 to 25 mg orally twice daily
- carvedilol
- diltiazem
0.25 mg/kg intravenous bolus initially, may give a second bolus of 0.35 mg/kg after 15 minutes if necessary, followed by 5-15 mg/hour infusion; 120-360 mg/day orally (regular-release) given in 3-4 divided doses
- diltiazem
- verapamil
5-10 mg intravenous bolus initially, may give a second bolus of 10 mg after 30 minutes if necessary, followed by a 0.005 mg/kg/minute infusion; 240-320 mg/day orally (regular-release) given in 3-4 divided doses; 180-480 mg orally (extended-release) once daily
- verapamil
Comments
- Rate-control therapy is required until cardioversion is successful.
- Intravenous administration of beta-blockers or calcium-channel blockers (CCBs) may be necessary for rapid control of ventricular rate. Furthermore, in the event of hemodynamic adverse effects, the infusion may be discontinued promptly.
- Beta-blockers and CCBs slow atrioventricular nodal conduction of cardiac impulses and subsequently reduce ventricular rate.
- Beta-blockers are particularly useful when new-onset AF is associated with an acute myocardial infarction or angina, and when new-onset AF is precipitated after exercise.
- Esmolol is useful in patients at risk of complications from beta-blockade, particularly those with reactive airway disease, left ventricular dysfunction, and/or peripheral vascular disease.
- CCBs are preferred in patients with chronic lung disease where bronchospasm may occur with beta-blockers.
- Both groups of medications may cause severe bradycardia, heart block, asystole, heart failure, or hypotension.
- If rate control is inadequate with monotherapy, a combination of a beta-blocker and CCB may be used. In addition, identification and treatment of any potential triggers of new-onset AF is very important, because rate and rhythm control measures are less likely to succeed if the acute precipitant persists.[41]
heparin
Primary Options
- heparin
see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds
- heparin
- enoxaparin
1 mg/kg subcutaneously every 12 hours
- enoxaparin
Comments
- Heparin should be started, and cardioversion should be delayed until the patient is established on heparin with a target activated partial thromboplastin time of 45-60 seconds.
electrical or pharmacologic cardioversion once heparin anticoagulation established
Primary Options
- flecainide
200-300 mg orally as a single dose
- flecainide
- propafenone
600 mg orally as a single dose
- propafenone
- amiodarone
150 mg intravenously initially over 10 minutes, followed by 1 mg/min infusion for 6 hours, and then 0.5 mg/min infusion for 18 hours; 600-800 mg/day orally given in 2-3 divided doses up to a total loading dose of up to 10 g, followed by 200 mg orally once daily
- amiodarone
- dronedarone
400 mg orally twice daily
- dronedarone
- ibutilide
0.01 mg/kg (maximum 1 mg/dose) intravenously initially, may repeat 10 minutes after initial dose if no response
- ibutilide
Comments
- Cardioversion may be carried out once heparin is established provided the transesophageal echocardiogram is negative. There is no significant difference in terms of outcome between DC and pharmacologic cardioversion. Timing of cardioversion in patients who are hemodynamically stable and minimally symptomatic is a topic of research. Some studies suggest no benefit of early cardioversion over a "wait and see" approach; others suggest outcomes are improved when cardioversion is performed early.[104] [105]
- DC cardioversion is fast, safe, and efficient.
- Class IC agents (flecainide, propafenone) have a higher mortality in patients with coronary artery disease (CAD) and are contraindicated in patients with CAD and cardiac dysfunction. AF may convert to atrial flutter that may conduct with rapid ventricular rate.
- Flecainide has strong evidence of efficacy for pharmacologic conversion (odds ratio [OR] 24.7, 95% CI 9.0 to 68.3). High conversion rate of about 70% at 3 hours after treatment and up to 90% at 8 hours.[151]
- Propafenone also has strong evidence of efficacy for pharmacologic conversion (OR 4.6, 95% CI 2.6 to 8.2). High conversion rates of up to 76% at 8 hours after treatment.[151]
- Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents in conversion to sinus rhythm.
- Dronedarone is a multichannel blocker and has noncompetitive anti-adrenergic activity.[106] [107] [108] It is less effective than amiodarone but has fewer side effects. Although not used primarily for cardioversion, it may be used for maintenance of cardioversion after successful cardioversion in clinically stable adult patients with paroxysmal or persistent AF and associated cardiovascular risk factors. It is contraindicated in patients with New York Heart Association (NYHA) class IV heart failure or NYHA class II or III heart failure with a recent (within the previous 4 weeks) decompensation requiring hospitalization or referral to a specialized heart failure clinic, and in patients with permanent AF.[135] [136]
- Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Up to 70% of all conversions occur within 20 minutes of infusion. It has strong evidence of efficacy for pharmacologic conversion (OR 29.1, 95% CI 9.8 to 86.1). Conversion rates are between 33% and 45% within the first 70 minutes. Because the half-life of ibutilide is 3-6 hours, prolonged observation period is recommended in patients who have received ibutilide.[151]
consideration of long-term aspirin post cardioversion
Primary Options
- aspirin
325 mg orally once daily
- aspirin
Comments
- Following successful cardioversion, heparin can be discontinued and aspirin alone considered for long-term prophylaxis if required.
without heart failure: CHA2DS2-VASc score ≥2
rate control with beta-blocker and/or calcium-channel blocker
Primary Options
- esmolol
500 micrograms/kg intravenously as a loading dose, followed by 50 micrograms/kg/min infusion for 4 minutes, if no response after 5 minutes, repeat loading dose and increase infusion, consult specialist for further guidance on dose
- esmolol
- metoprolol tartrate
2.5 to 5 mg intravenous bolus initially, may repeat every 5 minutes to a total of 3 doses; 25-200 mg orally (regular-release) twice daily
- metoprolol tartrate
- propranolol hydrochloride
1 mg intravenously initially, may repeat every 2 minutes to a total of 3 doses; 10-40 mg orally (immediate-release) three to four times daily
- propranolol hydrochloride
- atenolol
25-100 mg orally once daily
- atenolol
- nadolol
10-240 mg orally once daily
- nadolol
- bisoprolol
2.5 to 10 mg orally once daily
- bisoprolol
- carvedilol
3.125 to 25 mg orally twice daily
- carvedilol
- diltiazem
0.25 mg/kg intravenous bolus initially, may give a second bolus of 0.35 mg/kg after 15 minutes if necessary, followed by 5-15 mg/hour infusion; 120-360 mg/day orally (regular-release) given in 3-4 divided doses
- diltiazem
- verapamil
5-10 mg intravenous bolus initially, may give a second bolus of 10 mg after 30 minutes if necessary, followed by a 0.005 mg/kg/minute infusion; 240-320 mg/day orally (regular-release) given in 3-4 divided doses; 180-480 mg orally (extended-release) once daily
- verapamil
Comments
- Rate-control therapy is required until cardioversion is successful.
- Intravenous administration of beta-blockers or calcium-channel blockers (CCBs) may be necessary for rapid control of ventricular rate. Furthermore, in the event of hemodynamic adverse effects, the infusion may be discontinued promptly.
- Beta-blockers and CCBs slow atrioventricular nodal conduction of cardiac impulses and subsequently reduce ventricular rate.
- Beta-blockers are particularly useful when new-onset AF is associated with an acute myocardial infarction or angina, and when new-onset AF is precipitated after exercise.
- Esmolol is useful in patients at risk of complications from beta-blockade, particularly those with reactive airway disease, left ventricular dysfunction, and/or peripheral vascular disease.
- CCBs are preferred in patients with chronic lung disease where bronchospasm may occur with beta-blockers.
- Both groups of medications may cause severe bradycardia, heart block, asystole, heart failure, or hypotension.
- If rate control is inadequate with monotherapy, a combination of a beta-blocker and CCB may be used. In addition, identification and treatment of any potential triggers of new-onset AF is very important, because rate and rhythm control measures are less likely to succeed if the acute precipitant persists.[41]
anticoagulation
Primary Options
- dabigatran etexilate
150 mg orally twice daily
- dabigatran etexilate
- apixaban
2.5 to 5 mg orally twice daily
- apixaban
- edoxaban
60 mg orally once daily
- edoxaban
- rivaroxaban
20 mg orally once daily
- rivaroxaban
- heparin
see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds
or
- enoxaparin
1 mg/kg subcutaneously every 12 hours
AND
- warfarin
2-5 mg orally once daily initially, adjust dose according to target INR
- heparin
Comments
- Anticoagulation is recommended in all patients with AF due to the high risk of thromboembolic events. The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, apixaban, or edoxaban. DOACs are approved for stroke prevention and have a more favorable side-effect profile than vitamin K antagonists in patients with nonvalvular AF.
- All eligible patients should be started on a DOAC.[98]
- DOACs should be used with caution in patients with renal impairment. If a DOAC is suitable, depending on the degree of renal impairment and the indication for use, a dose adjustment may be required. Consult the prescribing information for specific guidance on use in patients with renal impairment.
- DOACs should not be used in patients with mechanical prosthetic valves or moderate-to-severe mitral stenosis, due to an increased risk of stroke, heart attack, and blood clot in these patients, nor should they be used in combination with heparin (including low molecular weight heparin), heparin derivatives, or warfarin.[110]
- In DOAC-ineligible patients, start concomitant heparin and warfarin therapy, and continue heparin until the warfarin levels are therapeutic (INR 2-3). Anticoagulation with warfarin at the target INR should be established for 3-4 weeks before cardioversion is attempted.
electrical or pharmacologic cardioversion following 3 to 4 weeks of anticoagulation
Primary Options
- flecainide
200-300 mg orally as a single dose
- flecainide
- propafenone
600 mg orally as a single dose
- propafenone
- amiodarone
150 mg intravenously initially over 10 minutes, followed by 1 mg/min infusion for 6 hours, and then 0.5 mg/min infusion for 18 hours; 600-800 mg/day orally given in 2-3 divided doses up to a total loading dose of up to 10 g, followed by 200 mg orally once daily
- amiodarone
- dronedarone
400 mg orally twice daily
- dronedarone
- ibutilide
0.01 mg/kg (maximum 1 mg/dose) intravenously initially, may repeat 10 minutes after initial dose if no response
- ibutilide
Comments
- Cardioversion should only be attempted once the patient has been established on anticoagulation with a target INR of 2 to 3 for 3-4 weeks.
- DC cardioversion is fast, safe, and efficient.
- Class IC agents (flecainide, propafenone) have a higher mortality in patients with coronary artery disease (CAD) and are contraindicated in patients with CAD and cardiac dysfunction. AF may convert to atrial flutter that may conduct with rapid ventricular rate.
- Flecainide has strong evidence of efficacy for pharmacologic conversion (odds ratio [OR] 24.7, 95% CI 9.0 to 68.3). High conversion rate of about 70% at 3 hours after treatment and up to 90% at 8 hours.[151]
- Propafenone also has strong evidence of efficacy for pharmacologic conversion (OR 4.6, 95% CI 2.6 to 8.2). High conversion rates of up to 76% at 8 hours after treatment.[151]
- Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents in conversion to sinus rhythm.
- Dronedarone is a multichannel blocker and has noncompetitive anti-adrenergic activity.[106] [107] [108] It is less effective than amiodarone but has fewer side effects. Although not used primarily for cardioversion, it may be used for maintenance of cardioversion after successful cardioversion in clinically stable adult patients with paroxysmal or persistent AF and associated cardiovascular risk factors. It is contraindicated in patients with New York Heart Association (NYHA) class IV heart failure or NYHA class II or III heart failure with a recent (within the previous 4 weeks) decompensation requiring hospitalization or referral to a specialized heart failure clinic, and in patients with permanent AF.[135] [136]
- Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Up to 70% of all conversions occur within 20 minutes of infusion. It has strong evidence of efficacy for pharmacologic conversion (OR 29.1, 95% CI 9.8 to 86.1). Conversion rates are between 33% and 45% within the first 70 minutes. Because the half-life of ibutilide is 3-6 hours, a prolonged observation period is recommended in patients who have received ibutilide.[151]
with heart failure
rate control with beta-blocker, digoxin, or amiodarone
Primary Options
- carvedilol
3.125 to 25 mg orally twice daily
- carvedilol
- metoprolol tartrate
2.5 to 5 mg intravenous bolus initially, may repeat every 5 minutes to a total of 3 doses; 25-200 mg orally (regular-release) twice daily
- metoprolol tartrate
- bisoprolol
2.5 to 10 mg orally once daily
- bisoprolol
- digoxin
0.75 to 1.5 mg orally as a loading dose given in divided doses on first day, followed by maintenance dose of 0.125 to 0.5 mg once daily
- digoxin
- amiodarone
300 mg intravenously initially over 1 hour, followed by 10-50 mg/hour infusion for 24 hours, and then 100-200 mg orally once daily
- amiodarone
Comments
- Patients with heart failure are considered at high risk of thromboembolism. Additional risk factors may also be present, including age ≥75 years, structural heart disease, diabetes, hypertension, rheumatic heart disease, prosthetic heart valves, or history of prior thromboembolism, and left ventricular ejection fraction is ≤35%.
- Beta-blockers, digoxin, or amiodarone may be used for rate control in patients with AF and heart failure.[1] These drugs may be used in combination or as monotherapy.
- Choice of pharmacologic agent/s in patients with heart failure is dictated by the degree of heart failure and type of heart failure (i.e., reduced or preserved ejection fraction [EF]). Drugs that potentially accentuate cardiac contractility are therefore avoided. Thus, calcium-channel blockers, which may be used in heart failure (HF) with preserved EF, are not recommended in patients with reduced EF (heart failure with reduced ejection fraction [HFrEF]). Beta-blockers such as carvedilol, metoprolol, and bisoprolol that are recommended for HF in patients with reduced and preserved EF may be used for rate control as well.
- Digoxin is not considered a first-line agent for the purpose of rate control, but it can be useful in patients with heart failure. One study explored whether digoxin use was independently associated with increased mortality in patients with AF; compared with propensity score-matched control participants, the risk of death and sudden death was significantly higher in new digoxin users.[103] In patients with AF taking digoxin, the risk of death was independently related to serum digoxin concentration and was highest in patients with concentrations of ≥1.2 ng/mL (≥1.54 nmol/L).[103]
- In addition, identification and treatment of any potential triggers of new-onset AF is very important, because rate and rhythm control measures are less likely to succeed if the acute precipitant persists.[41]
anticoagulation
Primary Options
- dabigatran etexilate
150 mg orally twice daily
- dabigatran etexilate
- apixaban
2.5 to 5 mg orally twice daily
- apixaban
- edoxaban
60 mg orally once daily
- edoxaban
- rivaroxaban
20 mg orally once daily
- rivaroxaban
- heparin
see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds
or
- enoxaparin
1 mg/kg subcutaneously every 12 hours
AND
- warfarin
2-5 mg orally once daily initially, adjust dose according to target INR
- heparin
Comments
- Anticoagulation is recommended in all patients with AF due to the high risk of thromboembolic events. The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, apixaban, or edoxaban. DOACs are approved for stroke prevention and have a more favorable side-effect profile than vitamin K antagonists in patients with nonvalvular AF.
- All eligible patients should be started on a DOAC.[98]
- DOACs should be used with caution in patients with renal impairment. If a DOAC is suitable, depending on the degree of renal impairment and the indication for use, a dose adjustment may be required. Consult the prescribing information for specific guidance on use in patients with renal impairment.
- DOACs should not be used in patients with mechanical prosthetic valves or moderate-to-severe mitral stenosis, due to an increased risk of stroke, heart attack, and blood clot in these patients, nor should they be used in combination with heparin (including low molecular weight heparin), heparin derivatives, or warfarin.[110]
- In DOAC-ineligible patients, start concomitant heparin and warfarin therapy, and continue heparin until the warfarin levels are therapeutic (INR 2-3). Anticoagulation with warfarin at the target INR should be established for 3-4 weeks before cardioversion is attempted.
electrical or pharmacologic cardioversion following 3 to 4 weeks of anticoagulation
Primary Options
- amiodarone
150 mg intravenously initially over 10 minutes, followed by 1 mg/min infusion for 6 hours, and then 0.5 mg/min infusion for 18 hours; 600-800 mg/day orally given in 2-3 divided doses up to a total loading dose of up to 10 g, followed by 200 mg orally once daily
- amiodarone
- ibutilide
0.01 mg/kg (maximum 1 mg/dose) intravenously initially, may repeat 10 minutes after initial dose if no response
- ibutilide
Comments
- Cardioversion should only be attempted once the patient has been established on anticoagulation with a target INR of 2 to 3 for 3-4 weeks.
- DC cardioversion is fast, safe, and efficient.
- Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents in conversion to sinus rhythm.
- Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Up to 70% of all conversions occur within 20 minutes of infusion. It has strong evidence of efficacy for pharmacologic conversion (OR 29.1, 95% CI 9.8 to 86.1). Conversion rates are between 33% and 45% within the first 70 minutes. Because the half-life of ibutilide is 3-6 hours, a prolonged observation period is recommended in patients who have received ibutilide.[151]
hemodynamically stable without left atrial thrombus: asymptomatic
CHA2DS2-VASc score 0-1
observation
Comments
- Most cases of new-onset AF revert to sinus rhythm spontaneously. Cases that revert spontaneously usually do so in the first 24 hours.[102]
- Patients should be observed to see whether AF resolves spontaneously.
- In addition, identification and treatment of any potential triggers of new-onset AF is very important, because rate and rhythm control measures are less likely to succeed, and AF is less likely to resolve spontaneously, if the acute precipitant persists.[41]
rate control with beta-blocker and/or calcium-channel blocker
Primary Options
- esmolol
500 micrograms/kg intravenously as a loading dose, followed by 50 micrograms/kg/min infusion for 4 minutes, if no response after 5 minutes, repeat loading dose and increase infusion, consult specialist for further guidance on dose
- esmolol
- metoprolol tartrate
2.5 to 5 mg intravenous bolus initially, may repeat every 5 minutes to a total of 3 doses; 25-200 mg orally (regular-release) twice daily
- metoprolol tartrate
- propranolol hydrochloride
1 mg intravenously initially, may repeat every 2 minutes to a total of 3 doses; 10-40 mg orally (immediate-release) three to four times daily
- propranolol hydrochloride
- atenolol
25-100 mg orally once daily
- atenolol
- nadolol
10-240 mg orally once daily
- nadolol
- bisoprolol
2.5 to 10 mg orally once daily
- bisoprolol
- carvedilol
3.125 to 25 mg orally twice daily
- carvedilol
- diltiazem
0.25 mg/kg intravenous bolus initially, may give a second bolus of 0.35 mg/kg after 15 minutes if necessary, followed by 5-15 mg/hour infusion; 120-360 mg/day orally (regular-release) given in 3-4 divided doses
- diltiazem
- verapamil
5-10 mg intravenous bolus initially, may give a second bolus of 10 mg after 30 minutes if necessary, followed by a 0.005 mg/kg/minute infusion; 240-320 mg/day orally (regular-release) given in 3-4 divided doses; 180-480 mg orally (extended-release) once daily
- verapamil
Comments
- If AF does not resolve spontaneously, rate-control therapy is required until cardioversion is successful.
- Beta-blockers and calcium-channel blockers (CCBs) slow atrioventricular nodal conduction of cardiac impulses and subsequently reduce ventricular rate.
- Intravenous administration of beta-blockers or calcium channel blockers may be necessary for rapid control of ventricular rate. Furthermore, in the event of hemodynamic adverse effects, the infusion may be discontinued promptly.
- Beta-blockers are particularly useful when new-onset AF is associated with an acute myocardial infarction or angina, and when new-onset AF is precipitated after exercise.
- Esmolol is useful in patients at risk of complications from beta-blockade, particularly those with reactive airway disease, left ventricular dysfunction, and/or peripheral vascular disease.
- CCBs are preferred in patients with chronic lung disease where bronchospasm may occur with beta-blockers.
- Both groups of medications may cause severe bradycardia, heart block, asystole, heart failure, or hypotension.
- If rate control is inadequate with monotherapy, a combination of a beta-blocker and CCB may be used.
electrical or pharmacologic cardioversion
Primary Options
- flecainide
200-300 mg orally as a single dose
- flecainide
- propafenone
600 mg orally as a single dose
- propafenone
- amiodarone
150 mg intravenously initially over 10 minutes, followed by 1 mg/min infusion for 6 hours, and then 0.5 mg/min infusion for 18 hours; 600-800 mg/day orally given in 2-3 divided doses up to a total loading dose of up to 10 g, followed by 200 mg orally once daily
- amiodarone
- dronedarone
400 mg orally twice daily
- dronedarone
- ibutilide
0.01 mg/kg (maximum 1 mg/dose) intravenously initially, may repeat 10 minutes after initial dose if no response
- ibutilide
Comments
- If AF does not resolve spontaneously, cardioversion may be attempted without the need for anticoagulation. There is no significant difference in terms of outcome between DC and pharmacologic cardioversion. Timing of cardioversion in patients who are hemodynamically stable and minimally symptomatic is a topic of research. Some studies suggest no benefit of early cardioversion over a "wait and see" approach; others suggest outcomes are improved when cardioversion is performed early.[104] [105]
- DC cardioversion is fast, safe, and efficient.
- Class IC agents (flecainide, propafenone) have a higher mortality in patients with coronary artery disease (CAD) and are contraindicated in patients with CAD and cardiac dysfunction. AF may convert to atrial flutter that may conduct with rapid ventricular rate.
- Flecainide has strong evidence of efficacy for pharmacologic conversion (odds ratio [OR] 24.7, 95% CI 9.0 to 68.3). High conversion rate of about 70% at 3 hours after treatment and up to 90% at 8 hours.[151]
- Propafenone also has strong evidence of efficacy for pharmacologic conversion (OR 4.6, 95% CI 2.6 to 8.2). High conversion rates of up to 76% at 8 hours after treatment.[151]
- Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents in conversion to sinus rhythm.
- Dronedarone is a multichannel blocker and has noncompetitive anti-adrenergic activity.[106] [107] [108] It is less effective than amiodarone but has fewer side effects. Although not used primarily for cardioversion, it may be used for maintenance of cardioversion after successful cardioversion in clinically stable adult patients with paroxysmal or persistent AF and associated cardiovascular risk factors. It is contraindicated in patients with New York Heart Association (NYHA) class IV heart failure or NYHA class II or III heart failure with a recent (within the previous 4 weeks) decompensation requiring hospitalization or referral to a specialized heart failure clinic, and in patients with permanent AF.[135] [136]
- Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Up to 70% of all conversions occur within 20 minutes of infusion. It has strong evidence of efficacy for pharmacologic conversion (OR 29.1, 95% CI 9.8 to 86.1). Conversion rates are between 33% and 45% within the first 70 minutes. Because the half-life of ibutilide is 3-6 hours, prolonged observation period is recommended in patients who have received ibutilide.[151]
CHA2DS2-VASc score ≥2
anticoagulation
Primary Options
- dabigatran etexilate
150 mg orally twice daily
- dabigatran etexilate
- apixaban
2.5 to 5 mg orally twice daily
- apixaban
- edoxaban
60 mg orally once daily
- edoxaban
- rivaroxaban
20 mg orally once daily
- rivaroxaban
- heparin
see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds
or
- enoxaparin
1 mg/kg subcutaneously every 12 hours
AND
- warfarin
2-5 mg orally once daily initially, adjust dose according to target INR
- heparin
Comments
- Patients with higher thromboembolic risk require immediate anticoagulation.
- The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, apixaban, or edoxaban. DOACs are approved for stroke prevention and have a more favorable side-effect profile than vitamin K antagonists in patients with nonvalvular AF.
- All eligible patients should be started on a DOAC.[98]
- DOACs should be used with caution in patients with renal impairment. If a DOAC is suitable, depending on the degree of renal impairment and the indication for use, a dose adjustment may be required. Consult the prescribing information for specific guidance on use in patients with renal impairment.
- DOACs should not be used in patients with mechanical prosthetic valves or moderate-to-severe mitral stenosis, due to an increased risk of stroke, heart attack, and blood clot in these patients, nor should they be used in combination with heparin (including low molecular weight heparin), heparin derivatives, or warfarin.[110]
- In DOAC-ineligible patients, start concomitant heparin and warfarin therapy, and continue heparin until the warfarin levels are therapeutic (INR 2-3). Anticoagulation with warfarin at the target INR should be established for 3-4 weeks before cardioversion is attempted.
observation
Comments
- Most cases of new-onset AF revert to sinus rhythm spontaneously. Cases that revert spontaneously usually do so in the first 24 hours.[102]
- Patients should be observed to see whether AF resolves spontaneously.
- In addition, identification and treatment of any potential triggers of new-onset AF is very important, because rate and rhythm control measures are less likely to succeed, and AF is less likely to resolve spontaneously, if the acute precipitant persists.[41]
rate control with beta-blocker and/or calcium-channel blocker
Primary Options
- esmolol
500 micrograms/kg intravenously as a loading dose, followed by 50 micrograms/kg/min infusion for 4 minutes, if no response after 5 minutes, repeat loading dose and increase infusion, consult specialist for further guidance on dose
- esmolol
- metoprolol tartrate
2.5 to 5 mg intravenous bolus initially, may repeat every 5 minutes to a total of 3 doses; 25-200 mg orally (regular-release) twice daily
- metoprolol tartrate
- propranolol hydrochloride
1 mg intravenously initially, may repeat every 2 minutes to a total of 3 doses; 10-40 mg orally (immediate-release) three to four times daily
- propranolol hydrochloride
- atenolol
25-100 mg orally once daily
- atenolol
- nadolol
10-240 mg orally once daily
- nadolol
- bisoprolol
2.5 to 10 mg orally once daily
- bisoprolol
- carvedilol
3.125 to 25 mg orally twice daily
- carvedilol
- diltiazem
0.25 mg/kg intravenous bolus initially, may give a second bolus of 0.35 mg/kg after 15 minutes if necessary, followed by 5-15 mg/hour infusion; 120-360 mg/day orally (regular-release) given in 3-4 divided doses
- diltiazem
- verapamil
5-10 mg intravenous bolus initially, may give a second bolus of 10 mg after 30 minutes if necessary, followed by a 0.005 mg/kg/minute infusion; 240-320 mg/day orally (regular-release) given in 3-4 divided doses; 180-480 mg orally (extended-release) once daily
- verapamil
Comments
- If AF does not resolve spontaneously, rate-control therapy is required until cardioversion is successful.
- Beta-blockers and calcium-channel blockers (CCBs) slow atrioventricular nodal conduction of cardiac impulses and subsequently reduce ventricular rate.
- Intravenous administration of beta-blockers or calcium channel blockers may be necessary for rapid control of ventricular rate. Furthermore, in the event of hemodynamic adverse effects, the infusion may be discontinued promptly.
- Beta-blockers are particularly useful when new-onset AF is associated with an acute myocardial infarction or angina, and when new-onset AF is precipitated after exercise.
- Esmolol is useful in patients at risk of complications from beta-blockade, particularly those with reactive airway disease, left ventricular dysfunction, and/or peripheral vascular disease.
- CCBs are preferred in patients with chronic lung disease where bronchospasm may occur with beta-blockers.
- Both groups of medications may cause severe bradycardia, heart block, asystole, heart failure, or hypotension.
- If rate control is inadequate with monotherapy, a combination of a beta-blocker and CCB may be used.
electrical or pharmacologic cardioversion
Primary Options
- flecainide
200-300 mg orally as a single dose
- flecainide
- propafenone
600 mg orally as a single dose
- propafenone
- amiodarone
150 mg intravenously initially over 10 minutes, followed by 1 mg/min infusion for 6 hours, and then 0.5 mg/min infusion for 18 hours; 600-800 mg/day orally given in 2-3 divided doses up to a total loading dose of up to 10 g, followed by 200 mg orally once daily
- amiodarone
- dronedarone
400 mg orally twice daily
- dronedarone
- ibutilide
0.01 mg/kg (maximum 1 mg/dose) intravenously initially, may repeat 10 minutes after initial dose if no response
- ibutilide
Comments
- If AF does not resolve spontaneously, cardioversion should only be attempted once the patient has been established on anticoagulation with a target INR of 2 to 3 for 3-4 weeks.
- DC cardioversion is fast, safe, and efficient.
- Class IC agents (flecainide, propafenone) have a higher mortality in patients with coronary artery disease (CAD) and are contraindicated in patients with CAD and cardiac dysfunction. AF may convert to atrial flutter that may conduct with rapid ventricular rate.
- Flecainide has strong evidence of efficacy for pharmacologic conversion (odds ratio [OR] 24.7, 95% CI 9.0 to 68.3). High conversion rate of about 70% at 3 hours after treatment and up to 90% at 8 hours.[151]
- Propafenone also has strong evidence of efficacy for pharmacologic conversion (OR 4.6, 95% CI 2.6 to 8.2). High conversion rates of up to 76% at 8 hours after treatment.[151]
- Class III agents (including amiodarone and ibutilide) are less efficacious than class IC agents in conversion to sinus rhythm.
- Dronedarone is a multichannel blocker and has noncompetitive anti-adrenergic activity.[106] [107] [108] It is less effective than amiodarone but has fewer side effects. Although not used primarily for cardioversion, it may be used for maintenance of cardioversion after successful cardioversion in clinically stable adult patients with paroxysmal or persistent AF and associated cardiovascular risk factors. It is contraindicated in patients with New York Heart Association (NYHA) class IV heart failure or NYHA class II or III heart failure with a recent (within the previous 4 weeks) decompensation requiring hospitalization or referral to a specialized heart failure clinic, and in patients with permanent AF.[135] [136]
- Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Up to 70% of all conversions occur within 20 minutes of infusion. It has strong evidence of efficacy for pharmacologic conversion (OR 29.1, 95% CI 9.8 to 86.1). Conversion rates are between 33% and 45% within the first 70 minutes. Because the half-life of ibutilide is 3-6 hours, prolonged observation period is recommended in patients who have received ibutilide.[151]
Emerging Tx
Vernakalant
Left atrial appendage occlusion
Colchicine
Factor XI inhibitors
Prevention
Primary Prevention
Secondary Prevention
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
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Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021 Feb 1;42(5):373-498.[Abstract][Full Text]
January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons. Circulation. 2019 Jul 9;140(2):e125-51. [Abstract][Full Text]
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Key Articles
Other Online Resources
Referenced Articles
Guidelines
Diagnostic
Summary
This is a standalone publication that includes recommendations on stroke and bleeding risk assessment in atrial fibrillation.Published by
European Society of Cardiology
Published
2020
Summary
Focused updates in areas for which new evidence has emerged since publication of the 2014 guidelines on optimum management of AF. Refer to 2014 guidelines for unchanged recommendations and for clinical areas not addressed in this focused update.Published by
American Heart Association; American College of Cardiology; Heart Rhythm Society
Published
2019
Summary
Revised guidelines for optimum management of AF. Refer to 2019 focused update in areas for which new evidence has emerged since publication of the 2014 guidelines on optimum management of AF.Published by
American Heart Association; American College of Cardiology; Heart Rhythm Society
Published
2014
Summary
Provides recommendations on the diagnosis of atrial fibrillation in adults.Published by
National Institute for Health and Care Excellence (UK)
Published
2021
Treatment
Summary
Canadian guidelines for the management of AF.Published by
Canadian Cardiovascular Society
Published
2020
Summary
Revised guidelines for optimum management of AF.Published by
American College of Cardiology; American Heart Association Task Force; Heart Rhythm Society
Published
2019
Summary
Evidence-based recommendations on the use of antithrombotic therapy in patients with AF.Published by
American College of Chest Physicians
Published
2018
Summary
Revised guidelines for optimum management of AF.Published by
American Heart Association; American College of Cardiology; Heart Rhythm Society
Published
2014
Summary
Evidence-based guidelines on the use of device-based therapy for a range of cardiac arrhythmias including atrial fibrillation.Published by
American College of Cardiology; American Heart Association
Published
2013
Summary
Practical, scenario-based guidance on the use of direct oral anticoagulants, to provide support for safe and effective use of nonvitamin K antagonist oral anticoagulants (NOACs) in daily practice, thereby supplementing the European Society of Cardiology and other international guidelines mainly focusing on the scientific evidence for treatment of patients with AF with anticoagulation in general and of NOACs in particular.Published by
European Heart Rhythm Association
Published
2021
Summary
Provides recommendations on the treatment of atrial fibrillation in adults.Published by
National Institute for Health and Care Excellence (UK)
Published
2021
Summary
This is a standalone publication that includes recommendations on the use of the novel oral anticoagulants, dabigatran, rivaroxaban, and apixaban.Published by
European Society of Cardiology
Published
2020