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 – WPW/rapid 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 - Hemodynamic instability: consider immediate DC cardioversion (2018, updated from 2014)
We recommend that immediate electrical cardioversion be considered for patients whose recent-onset AF/AFL is the direct cause of instability with hypotension, acute coronary syndrome, or pulmonary edema (Strong Recommendation, Low Quality Evidence).
Values and preferences (2018, updated from 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. Therapeutic anticoagulation therapy should be initiated as soon as possible.
Recommendation 6 - Lower stroke risk and AF < 48 hours, may undergo cardioversion (2018, updated from 2014)
We suggest that pharmacological or electrical cardioversion of symptomatic AF or AFL without at least three weeks of prior therapeutic anticoagulation be reserved for patients with the following characteristics (Weak Recommendation, Low Quality Evidence):
a) patients with non-valvular AF presenting with a clear AF-onset within 12 hours in the absence of recent stroke or TIA (within 6 months)
b) patients with non-valvular AF and a CHADS2 score < 2 presenting after 12 hours but within 48 hours of AF onset
Practical tip (2018)
Non-valvular AF is defined as AF in the absence of mechanical heart valves, rheumatic mitral stenosis, or moderate to severe nonrheumatic mitral stenosis.
Recommendation 7 – 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 8 - High stroke risk and cardioversion after TEE (2018, updated from 2014)
We suggest that, as an alternative to at least three weeks of therapeutic anticoagulation prior to cardioversion, transesophageal echocardiography (TEE) may be employed to exclude cardiac thrombus (Weak 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 9 - Immediate initiation of OAC for unplanned cardioversion (2018)
When a decision has been reached that a patient will be undergoing unplanned cardioversion of AF/AFL, we suggest that therapeutic anticoagulation therapy be initiated immediately (preferably before cardioversion) with either a NOAC, or with heparin followed by adjusted dose warfarin. (Weak recommendation, Low Quality Evidence).
Recommendation 10 - OAC for 4 weeks post cardioversion (2018)
We suggest that, in the absence of a strong contraindication, all patients undergoing cardioversion of AF/AFL receive at least four weeks of therapeutic anticoagulation (adjusted-dose warfarin or a NOAC) after cardioversion. (Weak recommendation, Low Quality Evidence). Thereafter, we recommend that the need for ongoing antithrombotic therapy should be based upon the risk of stroke as determined by the CCS algorithm (“CHADS-65”) (Strong Recommendation, Moderate Quality Evidence).
Values and preferences (2018)
This approach places relatively greater emphasis on the benefits of stroke prevention in comparison to the risks of bleeding with a short course of anticoagulation therapy. Although it may be possible to parse these risks based upon either patient characteristics or the duration of acute AF/AFL, the CCS AF Guidelines Committee at this point has chosen to simplify by recommending anticoagulation for one month after cardioversion for all such patients in the absence of a strong contraindication.
Practical tip (2018)
When oral anticoagulation is to be used for only a short period (less than two months) current evidence does not substantiate either an efficacy or safety advantage for use of a NOAC over adjusted dose warfarin. Nevertheless, the convenience of use of a NOAC over adjusted-dose warfarin in the peri-cardioversion period is substantial and the onset of therapeutic anticoagulation is nearly immediate with a NOAC while being delayed in the case of adjusted-dose warfarin. Accordingly, it is reasonable to use NOAC therapy in the peri-cardioversion period.
Recommendation 11 – 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 12 - 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 13 – 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.