Atrial Fibrillation: Cardioversion

Key points

• Haemodynamically unstable with acute AF → emergency electrical (DC) cardioversion, without delaying for anticoagulation.
• AF confirmed to be of less than 48 hours’ onset: rate or rhythm control may be offered · for cardioversion, heparinise and cardiovert electrically or pharmacologically · flecainide or amiodarone if there is no structural heart disease, amiodarone if there is.
• AF of more than 48 hours’ duration or uncertain onset: anticoagulate for at least 3 weeks before cardioversion, OR do a transoesophageal echo to exclude left atrial appendage thrombus and then cardiovert on heparin · electrical is preferred to pharmacological cardioversion here.
• High risk of cardioversion failure (previous failure or early recurrence): consider amiodarone for 4 weeks before, and up to 12 months after, electrical cardioversion.
• Anticoagulate for at least 4 WEEKS after cardioversion in every case · continue long term based on CHA2DS2-VASc, not on whether sinus rhythm was restored — a successful cardioversion does not remove the need for anticoagulation in someone with stroke risk factors.
• Anticoagulation for AF is now DOAC-first (NG196) — a vitamin K antagonist only if a DOAC is contraindicated, not tolerated or unsuitable.

Decision points in this pathway

• Haemodynamically unstable?
• AF definitely of less than 48 hours’ onset?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.