Cardioversion Elective Cardioversion
ÎFor patients with AF of > 48 h or unknown duration undergoing elective electrical or pharmacologic cardioversion, the ACCP recommends therapeutic anticoagulation ([INR 2.0-3.0], low-molecular-weight heparin [LMWH] at full venous thromboembolism treatment doses, or dabigatran) for at least 3 weeks before cardioversion or a transesophageal echocardiography (TEE)-guided approach with abbreviated anticoagulation before cardioversion (1B). The ACCP recommends therapeutic anticoagulation for at least 4 weeks after successful cardioversion to sinus rhythm, regardless of the baseline risk of stroke (1B). Decisions about anticoagulation beyond 4 weeks should be made in accordance with ACCP's risk-based recommendations for long-term antithrombotic therapy of nonrheumatic AF.
ÎFor patients with AF with a documented duration of ≤ 48 h undergoing elective cardioversion (electrical or pharmacologic), the ACCP suggests starting anticoagulation at presentation (LMWH or unfractionated heparin [UFH] at full venous thromboembolism treatment doses) and proceeding to cardioversion rather than delaying cardioversion for 3 weeks of therapeutic anticoagulation or a TEE-guided approach (2C). After successful cardioversion to sinus rhythm, the ACCP suggests therapeutic anticoagulation for at least 4 weeks, regardless of baseline stroke risk (2C). Decisions about long-term anticoagulation after cardioversion should be made in accordance with ACCP's risk-based recommendations for long- term antithrombotic therapy of nonrheumatic AF.
Urgent Cardioversion
ÎFor patients with AF and hemodynamic instability undergoing urgent cardioversion (electrical or pharmacologic), the ACCP suggests that therapeutic-dose parenteral anticoagulation be started before cardioversion, if possible (2C), but that initiation of anticoagulation must not delay any emergency intervention (2C). After successful cardioversion to sinus rhythm, the ACCP suggests therapeutic anticoagulation for at least 4 weeks, regardless of baseline stroke risk (2C). Decisions about anticoagulation beyond 4 weeks should be made in accordance with ACCP's risk-based recommendations for long-term antithrombotic therapy of nonrheumatic AF.
Atrial Flutter
ÎFor patients with atrial flutter undergoing elective or urgent pharmacologic or electrical cardioversion, the ACCP suggests that the same approach to thromboprophylaxis be used as for patients with AF undergoing cardioversion.
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