Table 11

Summary of Recommendations for Electrical and Pharmacological Cardioversion of AF and Atrial Flutter

RecommendationsCORLOEReferences
Prevention of thromboembolism
 With AF or atrial flutter for ≥48 h, or unknown duration, anticoagulate with warfarin for at least 3 wk before and 4 wk after cardioversionI(320–323)
 With AF or atrial flutter for >48 h or unknown duration, requiring immediate cardioversion, anticoagulate as soon as possible and continue for at least 4 wkICN/A
 With AF or atrial flutter <48 h and high stroke risk, IV heparin or LMWH, or factor Xa or direct thrombin inhibitor, is recommended before or immediately after cardioversion, followed by long-term anticoagulationICN/A
 Following cardioversion of AF, long-term anticoagulation should be based on thromboembolic riskICN/A
 With AF or atrial flutter for ≥48 h or unknown duration and no anticoagulation for preceding 3 wk, it is reasonable to perform TEE before cardioversion and then cardiovert if no LA thrombus is identified, provided anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 wkIIaB(164)
 With AF or atrial flutter ≥48 h or unknown duration, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for ≥3 wk before and 4 wk after cardioversionIIaC(230,324,325)
 With AF or atrial flutter <48 h and low thromboembolic risk, IV heparin, LMWH, a new oral anticoagulant, or no antithrombotic may be considered for cardioversionIIbC(326)
Direct-current cardioversion
 Cardioversion is recommended for AF or atrial flutter to restore sinus rhythm. If unsuccessful, cardioversion attempts may be repeated.IB(327)
 Cardioversion is recommended for AF or atrial flutter with RVR, that does not respond to pharmacological therapiesICN/A
 Cardioversion is recommended for AF or atrial flutter and pre-excitation with hemodynamic instabilityICN/A
 It is reasonable to repeat cardioversion in persistent AF when sinus rhythm can be maintained for a clinically meaningful time period between proceduresIIaCN/A
Pharmacological cardioversion
 Flecainide, dofetilide, propafenone, and IV ibutilide are useful for cardioversion of AF or atrial flutter, provided contraindications to the selected drug are absentIA(328–333)
 Amiodarone is reasonable for pharmacological cardioversion of AFIIaA(334,335)
 Propafenone or flecainide (“pill-in-the-pocket”) to terminate AF out of hospital is reasonable once observed to be safe in a monitored settingIIaB(328)
 Dofetilide should not be initiated out of hospitalIII: HarmB(332,336)

AF indicates atrial fibrillation; COR, Class of Recommendation; IV, intravenous; LA, left atrial; LMWH, low-molecular-weight heparin; LOE, Level of Evidence; N/A, not applicable; RVR, rapid ventricular response; and TEE, transesophageal echocardiography.