Cardioversion Curriculum
Learning Objectives
At the conclusion of this activity, the learner will be able to:
•
Identify appropriate anticoagulation strategies prior to and following
cardioversion.
•
Provide anticoagulation therapy for the appropriate period before and
after cardioversion.
•
Determine appropriate antiarrhythmic drug therapy to restore sinus
rhythm in patients who have AF of greater than or less than 7 days.
•
Administer antiarrhythmic drug therapy to prevent ERAF after
cardioversion.
•
Recognize that administration of antiarrythmic medication prior to
cardioversion may promote restoration of sinus rhythm and the
implications with respect to thromboembolism.
•
Recognize the different methods of cardioversion as well as both preand post-procedure anticoagulation strategies and anti-arrhythmic drug
management.
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Candidates for Elective Cardioversion
• Patients with a reasonable expectation to remain in sinus rhythm
• Patients with substantial symptoms in AF with good rate control
• Patients in whom the physician considers sinus rhythm the preferred
treatment strategy
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Special Considerations for Anticoagulation Prior to Cardioversion
• For patients with AF > 48 hours of AF, or when duration is unknown, 3
weeks of anticoagulation are required prior to cardioversion.
• Documentation of anticoagulation adequacy is important prior to
cardioversion
• It may take longer than 3 weeks to achieve 3 consecutive weeks of
adequate anticoagulation
• Anticoagulation must be continued for at least 4 weeks post
cardioversion
• TEE can be used to assess LA for thrombus as alternative to 3-week
anticoagulation (however, anti-coagulation must continue for 4 weeks
post cardioversion
Fuster et al. J Amer Coll Cardiol 2006; 48: 854-906
www.HRSonline.org
Prospective Companion of TEE-guided vs.
Conventional-treatment Cardioversion of A. Fib
Klein AL, N Engl J Med 2001; 344: 1411-20
Atrial fibrillation > 2 days’ duration,
DC cardioversion prescribed
Random assignment (1:1)
Transesophagealechocardiography group
Conventional treatment
group
Therapeutic anticoagulation
with heparin or warfarin
Thrombus detected
No DC cardioversion
No thrombus detected
DC cardioversion
Warfarin for 3 wk
Warfarin for 3 wk
Repeated transesophageal
echocardiography
No thrombus
DC cardioversion
Thrombus
No DC cardioversion
Warfarin for 4 wk
Warfarin for 4 wk
Warfarin for 4 wk
Warfarin for 4 wk
Follow-up examination
8 wk after assignment
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DC cardioversion
Clinical Outcomes of TEE-guided vs. Conventional-treatment
Cardioversion of A. Fib
Variable
TEE Guided (n= 619)
Conventional
Treatment (n=603)
80.3
79.9
Time to Cardioversion (d)
3.0 + 5.6*
30.6 + 10.6
Embolic Events (%)
5 (0.8%)
3 (0.5%)
Hemorrhagic events (%)
18 (2.9%)*
33 (5.5%)
Death (%)
15 (2.4%)
6 (1.0%)
52.7
50.4
Successful Cardioversion (%)
SR at 8 wks (%)
*significant
Klein AL, N Engl J Med 2001; 344: 1411-20
6
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Daily Incidence of AF Relapse After Electrical Cardioversion
Number of patients with relapse of AF
6
5
4
3
2
1
0
0
5
10
20
Days post cardioversion
Tieleman RG et al. J Am Coll Cardiol 1998; 31: 167-73
www.HRSonline.org
15
25
30
35
Procedural Aspects of Direct-current Cardioversion of Atrial
Fibrillation
• Ensure appropriate anticoagulation
• Use adequate general anesthesia in fasting state
• Electrodes positioned anterior-posterior or anterior-lateral
• Confirm R-wave synchronization
• Biphasic shock waveform preferable
• Determine the need for pretreatment with antiarrhythmic drugs
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Proportion, with 95% Confidence Interval
Cumulative Success in Cardioversion of A. Fib:
Biphasic vs. Monophasic Waveform
1.0
Biphasic
0.8
*
Monophasic
*
*
0.6
0.4
0.2
0.0
1st Shock
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1-2 Shocks
1-3 Shocks
Page RL et al. J Am Coll Cardiol 2002; 39: 1956-63
1-4 Shocks
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Recommendations for Direct-current Cardioversion of Atrial
Fibrillation
Class I
1. When a rapid ventricular response does not respond promptly to
pharmacological measures for patients with AF with ongoing myocardial
ischemia, symptomatic hypotension, angina, or HF, immediate R-wave
synchronized direct-current cardioversion is recommended. (Level of
Evidence: C)
2. Immediate direct-current cardioversion is recommended for patient with AF
involving preexcitation when very rapid tachycardia or hemodynamic
instability occurs. (Level of Evidence: B)
3. Cardioversion is recommended in patients without hemodynamic instability
when symptoms of AF are unacceptable to the patient. In case of early
relapse of AF after cardioversion, repeated direct-current cardioversion,
repeated direct-current cardioversion attempts may be made following
administration of antiarrhythmic medication.
(Level of Evidence: C)
ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246
www.HRSonline.org
Recommendations for Direct-current Cardioversion of Atrial
Fibrillation
Class IIa
1. Direct-current cardioversion can be useful to restore sinus rhythm as
part of a long-term management strategy for patients with AF. (Level
of Evidence: B)
2. Patient preference is a reasonable consideration in the selection of
infrequently repeated cardioversions for the management of
symptomatic or recurrent AF. (Level of Evidence: C)
ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246
www.HRSonline.org
Recommendations for Direct-current Cardioversion of Atrial
Fibrillation
Class III
1. Frequent repetition of direct-current cardioversion is not
recommended for patients who have relatively short periods of sinus
rhythm between relapses of AF after multiple cardioversion
procedures despite prophylactic antiarrhythmic drug therapy. (Level
of Evidence: C)
2. Electrical cardioversion is contraindicated in patients with digitalis
toxicity or hypokalemia. (Level of Evidence: C)
ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246
www.HRSonline.org
Pharmacological Cardioversion of Atrial Fibrillation
< 7 days Duration
Drug
Class of Recommendation (level
of evidence)
Agents with proven efficacy
Dofetilide
I (A)
Flecainide
I (A)
Ibutilide
I (A)
Propafenone
I (A)
Amiodarone
IIa (A)
Less effective or incompletely studied
Disopyramide
IIb (B)
Procainamide
IIb (B)
Quinidine
IIb (B)
Should not be administered
Digoxin
III (A)
Sotalol
III (A)
Modified from: ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246
15
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Successful Conversion Rate of Atrial Fibrillation and Flutter with
Intravenous Ibutilide vs. Procainamide
100
Ibutilide
**
Success rate (%)
80
60
*
Procainamide
***
40
20
0
Combined
Volgman AS et al. J Am Coll Cardiol 1998; 31: 1414-19
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Flutter
Fibrillation
Success Rates of Conversion to Sinus Rhythm with Vernakalant
Compared with Placebo
P<0.001
60
Vernakalant
Placebo
51.7
50
Percentage
P<0.001
37.6
40
30
20
P=0.09
7.9
10
4.0
2.6
0
0
(n=75)
(n=145)
Short-Duration AF
Roy D Circulation 2008; 117:1518-1525
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(n=40)
(n=76)
Long-duration AF
(n=115) (n=221)
Overall Population
Cumulative Success Rates of Conversion to Sinus Rhythm Over
Time with Vernakalant vs. Placebo
Proportion of Patients with
Conversion to SR
0.6
Vernakalant
Placebo
0.5
0.4
P<.001 (Log-Rank Test)
0.3
0.2
0.1
0
20
40
60
80
0 100 Time from First Infusion of Study Drug (min.)
Roy D Circulation 2008; 117:1518-1525
www.HRSonline.org
Pharmacological Cardioversion of Atrial Fibrillation
> 7 days Duration
Drug
Class of Recommendation (level
of evidence)
Agents with proven efficacy
Dofetilide
I (A)
Amiodarone
IIa (A)
Ibutilide
IIa (A)
Less effective or incompletely studied
Disopyramide
IIb (B)
Flecainide
IIb (B)
Procainamide
IIb (B)
Propafenone
IIb (B)
Quinidine
IIb (B)
Should not be administered
Digoxin
III (B)
Sotalol
III (B)
Modified from: ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246
19
www.HRSonline.org
Outpatient Treatment of Recent-onset Atrial Fibrillation with the
“Pill-in-the-Pocket” Approach
• 268 consecutive patients with recent-onset (< 48 hours) A. Fib with
mean heart rate > 70/min and systolic BP > 100mmHg
• Patients treated in emergency room or cardiology ward
• Some exclusions:
• Preexcitaiton; BB block; IHD; DCM; HCM;
• History of HF; prev AF > 7 days duration
• Single oral AA drug dose:
• Flecainide 300mg (>70kg); 200mg (<70kg)
• Propafenone 600mg (>70kg); 450mg (<70kg)
• 58 (22%) patients excluded because of treatment failures or side
effects (n=14)
• hypotension (n=4); symptomatic bradycardia (n=3); transient A Fl (n=7)
Alboni P et al. N Engl J Med 2004; 351: 2384-91
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“Pill-in-the-Pocket” Approach to Cardiovert A. Fib
Alboni P et al. N Engl J Med 2004; 351: 2384-91
268 patients treated
in hospital
58 patients excluded
- 3 patients (1%) met
echocardiographic
exclusion criteria
- 41 patients (15%)
had drug inefficacy
- 14 patients (5%) had
adverse effects
210 patients enrolled for
out-of-hospital treatment
4 patients (2%) lost to
follow-up
41 patients (20%) had no
recurrence
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165 patients (79%) had
recurrences
“Pill-in-the-Pocket” Approach to Cardiovert A. Fib
165 patients (79%) had
recurrences
618 arrhythmic episodes
49 untreated episodes (8%)
569 treated episodes (92%)
5 episodes (10%) involved
534 episodes (94%)
interrupted < 6 hr
ER contact
16 episodes (3%) interrupted
> 6hr; did not contact ER
26 episodes (5%) involved
ER contact
Alboni P et al. N Engl J Med 2004; 351: 2384-91
Total of 31 episodes (5%
involved ER contact
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Recommendations for Pharmacological Cardioversion of Atrial
Fibrillation
Class I
• Administration of flecainide, dofetilide, propafenone, or ibutilide is
recommended for pharmacological cardioversion of AF. (Level of
Evidence: A)
ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246
www.HRSonline.org
Recommendations for Pharmacological Cardioversion of Atrial
Fibrillation
Class IIa
1. Administration of amiodarone is a reasonable option for
pharmacological cardioversion of AF. (Level of Evidence: A)
2. A single oral bonus dose of propafenone or flecainide (“pill-in-thepocket”) can be administered to terminate persistent AF outside the
hospital once treatment has proved safe in a hospital for selected
patients without sinus or AV node dysfunction, bundle-branch
block,QT-interval prolongation, the Brugada syndrome, or structural
heart disease. Before antiarrhythmic medication is initiated, a beta
blocker or nondihydropyridine calcium channel antagonist should be
given to prevent rapid AV conduction in the event atrial flutter occurs.
(Level of Evidence: C)
3. Administration of amiodarone can be beneficial on an outpatient basis
in patients with paroxysmal or persistent AF when rapid restoration of
sinus rhythm is not deemed necessary. (Level of Evidence: C)
ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246
www.HRSonline.org
Recommendations for Pharmacological Cardioversion of Atrial
Fibrillation
Class IIb
• Administration of quinidine or procainamide might be considered for
pharmacological cardioversion of AF, but the usefulness of these
agents is not well established. (Level of Evidence: C)
ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246
www.HRSonline.org
Recommendations for Pharmacological Cardioversion of Atrial
Fibrillation
Class III
1. Digoxin and sotalol may be harmful when used for pharmacological
cardioversion of AF and are not recommended. (Level of Evidence: A)
2. Quinidine, procainamide, disopyramide, and dofetilide should not be
started out of hospital for conversion of AF to sinus rhythm. (Level of
Evidence: B)
ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246
www.HRSonline.org