Atrial Fibrillation: Pharmacological Cardioversion

Key points

• Agents with proven efficacy for pharmacological cardioversion: flecainide (only if there is NO structural or ischaemic heart disease) and amiodarone · others used less in the UK include propafenone, ibutilide, dofetilide and vernakalant.
• Flecainide is the agent most likely to cardiovert recent-onset AF when the heart is structurally normal — it is contraindicated in structural or ischaemic heart disease because of proarrhythmia.
• Amiodarone is the choice where there is structural heart disease, ischaemic heart disease or left ventricular impairment.
• Less effective for cardioversion: beta-blockers (including sotalol) · rate-limiting calcium-channel blockers · digoxin · these control rate rather than restore rhythm.
• Anticoagulation rules are the same as for electrical cardioversion — onset over 48 hours or uncertain requires 3 weeks of anticoagulation beforehand or a TOE, and at least 4 weeks afterwards in every case.

Decision points in this pathway

• Structural or ischaemic heart disease present?

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