15
Table 10. Electrical and Pharmacological Cardioversion of
AF and Atrial Flutter
Recommendations COR LOE
Prevention of romboembolism
For patients with AF or atrial flutter of ≥48-hours' duration,
or when the duration of AF is unknown, anticoagulation with
warfarin (INR 2.0-3.0) is recommended for ≥3 weeks prior to
and 4 weeks aer cardioversion, regardless of the CHA
2
DS
2
-
VASc score and the method (electrical or pharmacological)
used to restore sinus rhythm.
I B
For patients with AF or atrial flutter of >48 hours duration or
unknown duration that requires immediate cardioversion for
hemodynamic instability, anticoagulation should be initiated
as soon as possible and cont'd for ≥4 weeks aer cardioversion
unless contraindicated.
I C
For patients with AF or atrial flutter of <48-hour duration
and with high risk of stroke, intravenous heparin or LMWH,
or administration of a factor Xa or direct thrombin inhibitor,
is recommended as soon as possible before or immediately
aer cardioversion, followed by long-term anticoagulation
therapy.
I C
Following cardioversion for AF of any duration, the decision
about long-term anticoagulation therapy should be based on
the thromboembolic risk profile.
I C
For patients with AF or atrial flutter of ≥48-hours duration
or of unknown duration who have not been anticoagulated
for the preceding 3 weeks, it is reasonable to perform TEE
before cardioversion and proceed with cardioversion if no LA
thrombus is identified, including in the LAA, provided that
anticoagulation is achieved before TEE and maintained aer
cardioversion for ≥4 weeks.
IIa B
For patients with AF or atrial flutter of ≥48-hour duration
or when duration of AF is unknown, anticoagulation with
dabigatran, rivaroxaban, or apixaban is reasonable for
≥3 weeks before and 4 weeks aer cardioversion.
IIa C
For patients with AF or atrial flutter of <48-hours duration
who are at low thromboembolic risk, anticoagulation
(intravenous heparin, LMWH, or a new oral anticoagulant)
or no antithrombotic therapy may be considered for
cardioversion, without the need for postcardioversion oral
anticoagulation.
IIb C
