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). (Strong recommendation, Low Quality Evidence)

Practical Tip: Caution is required in patients with permanent AF who present with instability as they may not benefit from cardioversion and may be made worse by attempts to do so.

Practical Tip: In patients with long standing AF and hemodynamic instability and a ventricular rate less than 150 beats per minute, the instability is likely due to causes other than AF (e.g. hypoxia, pain, sepsis) and is unlikely to respond to cardioversion.

Practical Tip: Immediate and adequate rate control may alleviate the clinical instability and obviate the need for immediate cardioversion.