What is the role of synchronized electrical cardioversion in the treatment of atrial fibrillation (AF)?

Updated: Nov 28, 2018
  • Author: Sean C Beinart, MD, MSc, FACC, FHRS; Chief Editor: Jose M Dizon, MD  more...
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Treatment strategies for atrial fibrillation include the following:

  • If the patient is clinically unstable, emergent cardioversion is recommended. Stable patients should have their ventricular rate controlled, and most should be anticoagulated with intravenous heparin and started on warfarin for stroke prevention because of a high risk of thromboembolism. If a high degree of certainty exists that atrial fibrillation is of less than 48 hours' duration, then a patient can proceed to cardioversion.

  • If the arrhythmia is of uncertain duration or of confirmed duration longer than 48 hours, then the patient can proceed to transesophageal echocardiography (TEE) for the evaluation of a thrombus in the atrium or appendage (a suggestion of smoke, or stagnant blood flow, is considered positive by some authorities). If the TEE findings are negative, the patient can proceed to elective cardioversion. Otherwise, these patients should be anticoagulated for 3 weeks before cardioversion with a repeat TEE.

  • All patients should be anticoagulated with warfarin for 4 weeks after cardioversion, because mechanical function of the atrium lags by up to 7 days after the restoration of sinus rhythm. If the foregoing treatment fails, patients can be managed with medical treatment alone, repeat cardioversion after antiarrhythmic (eg, ibutilide) treatment, ablation therapy, or atrial defibrillation. [15]

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