Recommendation 1 – Rate or rhythm control therapy for patients with recent onset AF/AFL (2010)
We recommend that in stable patients with recent-onset AF/AFL, a strategy of rate control or rhythm control could be selected (Strong Recommendation, High Quality Evidence).
Values and preferences (2010)
This recommendation places a high value on the randomized controlled trials investigating rate control as an alternative to rhythm control for AF/AFL, recognizing that these trials did not specifically address the ED environment.
Recommendation 2 – Hemodynamically stable patients with AF/AFL <48 hours (2010)
In hemodynamically stable patients with AF/AFL of known duration <48 hours in whom a strategy of rhythm control has been selected:
Values and preferences (2010)
These recommendations place a high value on determination of the duration of AF/AFL as a determinant of stroke risk with cardioversion. Also, individual considerations of the patient and treating physician are recognized in making specific decisions about method of cardioversion.
Recommendation 3 – Electrical cardioversion with 150-200 joules biphasic waveform (2010)
We recommend that electrical cardioversion may be conducted in the ED with 150-200 joules biphasic waveform as the initial energy setting (Strong Recommendation, Low- Quality Evidence).
Values and preferences (2010)
This recommendation places a high value on the avoidance of repeated shocks and the avoidance of ventricular fibrillation that can occur with synchronized cardioversion of AF at lower energy levels. It is recognized that the induction of VF is a rare but easily avoidable event.
Recommendation 4 – WPWrapid response, DC cardioversion for hemodynamically unstable (2010)
We recommend, in patients with rapid ventricular preexcitation during AF (Wolff-Parkinson-White syndrome):
Values and preferences (2010)
These recommendations place a high value on avoidance of the degeneration of preexcited AF to ventricular fibrillation. It is recognized that degeneration can occur spontaneously or it can be facilitated by the administration of specific agents that in the absence of ventricular preexcitation would be the appropriate therapy for rate control of AF.
Recommendation 5 – Lower stroke risk and AF 48 hours, may undergo cardioversion (2014)
For patients with no high-risk factors for stroke (recent stroke or TIA within 6 months; rheumatic heart disease; mechanical valve) and clear AF-onset within 48 hours or therapeutic OAC therapy for ≥3 weeks, we recommend that they may undergo cardioversion in the ED without immediate initiation of anticoagulation. Following attempted or successful cardioversion, antithrombotic therapy should be initiated as per the CCS algorithm. (Strong recommendation, Moderate Quality Evidence)
Values and preferences (2014)
This recommendation places high value on the symptomatic improvement with immediate cardioversion for those at very low risk of stroke.
Recommendation 6 – High stroke risk: rate control and OAC therapy 3 weeks precardioversion (2014)
For patients at high risk of stroke with cardioversion (not receiving therapeutic OAC therapy for ≥3 weeks with any of the following: AF episode duration not clearly <48 hours; stroke or TIA within 6 months; rheumatic heart disease; mechanical valve), we recommend optimized rate-control and therapeutic OAC for 3 weeks before and at least 4 weeks after cardioversion. (Strong Recommendation, Moderate Quality Evidence)
Values and preferences (2014)
These recommendations place a high value on minimizing stroke risk by a strategy of rate control, appropriate anticoagulation and delayed cardioversion and a lower value on symptomatic improvement associated with immediate cardioversion.
Recommendation 7 – High stroke risk and cardioversion after TEE (2014)
We suggest that patients at high risk of stroke (not receiving therapeutic OAC therapy for ≥3 weeks with any of the following: AF episode duration not clearly <48 hours; stroke or TIA within 6 months; rheumatic heart disease; mechanical valve) may undergo cardioversion guided by transesophageal echocardiography with immediate initiation of intravenous or low molecular weight heparin prior to cardioversion followed by therapeutic OAC for at least 4 weeks post cardioversion. (Conditional Recommendation, Moderate Quality Evidence)
Values and preferences (2014)
This recommendation places a high value on the symptomatic improvement with immediate cardioversion as well as the reduced risk of peri-cardioversion stroke conferred by a transesophageal echocardiogram demonstrating an absence of intracardiac thrombus. Lower value is placed on the small risks associated with the TEE.
Recommendation 8 – Hemodynamic instability: consider immediate DC cardioversion (2014)
For patients whose recent-onset AF/AFL is the direct cause of instability with hypotension, acute coronary syndrome, or florid pulmonary edema, we recommend that immediate electrical cardioversion be considered with immediate initiation of intravenous or low molecular weight heparin prior to cardioversion followed by therapeutic OAC for 4 weeks afterwards (unless AF-onset was clearly within 48 hours or the patient has received therapeutic OAC for >3 weeks) followed by therapeutic OAC for at least 4 weeks post cardioversion (Strong recommendation, Low Quality Evidence).
Values and preferences (2014)
This recommendation places a high value on immediately addressing instability by attempting cardioversion, and a lower value on reducing the risk of cardioversion-associated stroke with a period of anticoagulation pre-cardioversion.
Recommendation 9 – Hospital admission for decompensated HF or myocardial ischemia (2010)
We recommend hospital admission for highly symptomatic patients with decompensated heart failure or myocardial ischemia (Strong Recommendation, Low Quality Evidence).
Recommendation 10 - Admission for highly symptomatic patients with unachievable rate control (2010)
We suggest limiting hospital admission to highly symptomatic patients in whom adequate rate control cannot be achieved (Conditional Recommendation, Low Quality Evidence).
Values and preferences (2010)
Recommendation 9 and 10 place a high value on the need for monitoring of the response to therapy and its reassessment, as well as ancillary investigation and treatment not available in the ED in patients with complex medical conditions associated with AF/AFL. A lower value is placed on the attendant costs of admission to hospital in patients with complex medical conditions associated with AF/AFL.
Recommendation 11 – Antiarrhythmic drug therapy post-cardioversion (2010)
We suggest that after conversion to sinus rhythm has been achieved, whether antiarrhythmic drug therapy is indicated should be based on the estimated probability of recurrence and the symptoms during AF. Long-term therapy will need to be determined by an appropriate outpatient consultation (Conditional Recommendation, Low Quality Evidence).
Values and preferences (2010)
This recommendation places a high value on minimizing the risk of infrequent but serious side effects associated with long-term antiarrhythmic drugs. A high value is also placed on the appropriate use of specialty care to make patient-specific decisions to minimize these risks. A lower value is placed on the avoidance of symptoms associated with subsequent episodes of AF/AFL.