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Atrial Fibrillation 2023 Update

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86 Management 8.2.2. Electrical Cardioversion COR LOE Recommendations 1 C-LD 1. In patients with hemodynamic instability attributable to AF, immediate electrical cardioversion should be performed to restore sinus rhythm. 1 B-R 2. In patients with AF who are hemodynamically stable, electrical cardioversion can be performed as initial rhythm- control strateg y or following failed pharmacological cardioversion. 1 C-LD 3. In patients with AF undergoing electrical cardioversion, energ y delivery should be confirmed to be synchronized to the QRS to reduce the risk of inducing ventricular fibrillation (VF). 2a B-R 4. For patients with AF undergoing elective electrical cardioversion, the use of biphasic energ y of at least 200 J as initial energ y can be beneficial to improve success of initial electrical shock. 2a B-NR 5. In patients with AF undergoing elective cardioversion, with longer duration of AF or failed initial shock, optimization of electrode vector, use of higher energ y, and pretreatment with AADs can facilitate success of electrical cardioversion. 2b C-LD 6. In patients with obesity and AF, use of manual pressure augmentation and/or further escalation of electrical energ y may be beneficial to improve success of electrical cardioversion.

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