16
Treatment
Table 10. Electrical and Pharmacological Cardioversion
of AF and Atrial Flutter (cont'd)
Recommendations COR LOE
Direct-Current Cardioversion
In pursuing a rhythm-control strateg y, cardioversion
is recommended for patients with AF or atrial flutter
as a method to restore sinus rhythm. If cardioversion
is unsuccessful, repeated attempts at direct-current
cardioversion may be made aer adjusting the location of the
electrodes, applying pressure over the electrodes or following
administration of an antiarrhythmic medication.
I B
Cardioversion is recommended when a RVR to AF or atrial
flutter does not respond promptly to pharmacological
therapies and contributes to ongoing myocardial ischemia,
hypotension, or HF.
I C
Cardioversion is recommended for patients with AF or atrial
flutter and pre-excitation when tachycardia is associated with
hemodynamic instability.
I C
It is reasonable to perform repeated cardioversions in
patients with persistent AF, provided that sinus rhythm can
be maintained for a clinically meaningful period between
cardioversion procedures. Severity of AF symptoms and
patient preference should be considered when embarking on a
strateg y requiring serial cardioversion procedures.
IIa C
Pharmacological Cardioversion
Flecainide, dofetilide, propafenone, and intravenous ibutilide
are useful for pharmacological cardioversion of AF or atrial
flutter, provided contraindications to the selected drug are
absent.
I A
Administration of oral amiodarone is a reasonable option for
pharmacological cardioversion of AF.
IIa A
Propafenone or flecainide ("pill-in-the-pocket") in addition
to a beta blocker or nondihydropyridine calcium channel
antagonist is reasonable to terminate AF outside the hospital
once this treatment has been observed to be safe in a
monitored setting for selected patients.
IIa B
Dofetilide therapy should NOT be initiated out of hospital
because of the risk of excessive QT prolongation that can
cause torsades de pointes.
III: Harm B
