cardioversion
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Indications
Management
- see defibrillation for ventricular tachycardia & ventricular fibrillation
- cardioversion for atrial fibrillation/flutter
- DC cardioversion (50, 100, 200, 300, 360 joules)
- synchronized transthoracic DC cardioversion[2]
- 67-100% efficiency
- ibutilide IV prior to cardioversion decreases energy required for cardioversion
- risks
- anesthetic
- ventricular fibrillation from poor synchronization
- transvenous electrical cardioversion[2]
- useful when transthoracic cardioversion has failed
- usually shock between electrodes in right atrium & coronary sinus & or indifferent electrodes on the back
- low energies often effective
- monophasic defibrillator: 360 J single shock
- DC cardioversion more effective than chemical cardioversion[3]
- synchronized transthoracic DC cardioversion[2]
- chemical cardioversion
- pharmacologic agents
- class 1A, 1C or 3 antiarrhythmic agents
- conversion & maintenance of sinus rhythm
- pharmacologic agents
- indications
- patient is unstable
- mitral stenosis
- mitral regurgitation
- new onset of atrial fibrillation within 48 hours
- anticoagulation for patients with long-term AF*
- 3 weeks prior to elective cardioversion
- 4 weeks after successful cardioversion
- edoxaban as safe & effective as enoxaparin-warfarin[4]
- cardioversion may itself not cause thromboembolism[5]
- antiarrhythmic therapy for maintenance of sinus rhythm
- may or may not be needed
- amiodarone (most commonly used)
- 400 mg for 30 days, then 200 mg QD
- especially useful with structural heart disease
- if no structural heart disease
- flecainide 100 mg BID, or
- propafenone 150-225 mg TID
- 30-50% of patients will maintain sinus rhythm after 1-2 years
- DC cardioversion (50, 100, 200, 300, 360 joules)
Notes
- since atrial fibrillation usually involves the left atrium, elective attempts at chemical or electrical cardioversion should be preceded by anticoagulation therapy of at least 3 weeks duration to minimize the risk of systemic embolization upon restoration of sinus rhythm
- alternatively, atrial thrombi may be excluded by transesophageal echocardiogram
- following conversion to sinus rhythm, type Ia antiarrhythmic agents (quinidine, procainamide) or type III antiarrhythmic agents (amiodarone, sotalol) can be used in an effort to sustain sinus rhythm
- because atrial contractility may take up to a month to recover (atrial stunning), it is recommended to continue anticoagulation for 4 weeks after successful cardioversion
More general terms
More specific terms
- chemical cardioversion
- defibrillation (electrical cardioversion, automated external difibrillation, AED)
- synchronized cardioversion
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 238-40
- ↑ Jump up to: 2.0 2.1 2.2 Feliciano, Z. In: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ Jump up to: 3.0 3.1 Bellone A et al. Cardioversion of acute atrial fibrillation in the emergency department: A prospective randomised trial. Emerg Med J 2012 Mar; 29:188. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21422032
- ↑ Jump up to: 4.0 4.1 Goette A, Merino JL, Ezekowitz MD et al. Edoxaban versus enoxaparin-warfarin in patients undergoing cardioversion of atrial fibrillation (ENSURE-AF): A randomised, open-label, phase 3b trial. Lancet 2016 Aug 30; [e-pub]. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27590218 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31474-X/fulltext
Briasoulis A, Afonso L Do NOACs ENSURE safe cardioversion in atrial fibrillation? Lancet 2016 Aug 30 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27590222 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31410-6/fulltext - ↑ Jump up to: 5.0 5.1 McIntyre WF, Connolly SJ, Wang J et al. Thromboembolic events around the time of cardioversion for atrial fibrillation in patients receiving antiplatelet treatment in the ACTIVE trials. Eur Heart J 2019 Aug 4 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31377776 https://academic.oup.com/eurheartj/article/40/36/3026/5543556