UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Atrial fibrillation: Cardioversion to sinus rhythm

Authors
Gerald V Naccarelli, MD
Leonard I Ganz, MD, FHRS, FACC
Warren J Manning, MD
Section Editors
Bradley P Knight, MD, FACC
Brian Olshansky, MD
James Hoekstra, MD
Deputy Editor
Gordon M Saperia, MD, FACC

INTRODUCTION

The restoration (cardioversion) of sinus rhythm is performed in many patients with atrial fibrillation to improve symptoms. This topic will focus on our approach to cardioversion and the efficacy and safety of the two most widely used approaches: direct current and pharmacologic cardioversion. Other related topics include:

(See "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Clinical trials".)

(See "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations".)

(See "Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation".)

INDICATIONS

The restoration of sinus rhythm (SR) is performed in the following settings to improve symptoms and in the case of hemodynamic instability to improve short-term outcome:

                        

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Mon Oct 10 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Manning WJ, Silverman DI, Katz SE, et al. Impaired left atrial mechanical function after cardioversion: relation to the duration of atrial fibrillation. J Am Coll Cardiol 1994; 23:1535.
  2. Naccarelli GV, Dell'Orfano JT, Wolbrette DL, et al. Cost-effective management of acute atrial fibrillation: role of rate control, spontaneous conversion, medical and direct current cardioversion, transesophageal echocardiography, and antiembolic therapy. Am J Cardiol 2000; 85:36D.
  3. Falk RH. Atrial fibrillation. N Engl J Med 2001; 344:1067.
  4. Resnekov L, McDonald L. Appraisal of electroconversion in treatment of cardiac dysrhythmias. Br Heart J 1968; 30:786.
  5. Elhendy A, Gentile F, Khandheria BK, et al. Predictors of unsuccessful electrical cardioversion in atrial fibrillation. Am J Cardiol 2002; 89:83.
  6. Gallagher MM, Guo XH, Poloniecki JD, et al. Initial energy setting, outcome and efficiency in direct current cardioversion of atrial fibrillation and flutter. J Am Coll Cardiol 2001; 38:1498.
  7. Dittrich HC, Erickson JS, Schneiderman T, et al. Echocardiographic and clinical predictors for outcome of elective cardioversion of atrial fibrillation. Am J Cardiol 1989; 63:193.
  8. Henry WL, Morganroth J, Pearlman AS, et al. Relation between echocardiographically determined left atrial size and atrial fibrillation. Circulation 1976; 53:273.
  9. Lundström T, Rydén L. Chronic atrial fibrillation. Long-term results of direct current conversion. Acta Med Scand 1988; 223:53.
  10. Dalzell GW, Anderson J, Adgey AA. Factors determining success and energy requirements for cardioversion of atrial fibrillation. Q J Med 1990; 76:903.
  11. Pritchett EL. Management of atrial fibrillation. N Engl J Med 1992; 326:1264.
  12. Dell'Orfano JT, Patel H, Wolbrette DL, et al. Acute treatment of atrial fibrillation: spontaneous conversion rates and cost of care. Am J Cardiol 1999; 83:788.
  13. Danias PG, Caulfield TA, Weigner MJ, et al. Likelihood of spontaneous conversion of atrial fibrillation to sinus rhythm. J Am Coll Cardiol 1998; 31:588.
  14. Schwartzman D, Musley SK, Swerdlow C, et al. Early recurrence of atrial fibrillation after ambulatory shock conversion. J Am Coll Cardiol 2002; 40:93.
  15. Gurevitz OT, Ammash NM, Malouf JF, et al. Comparative efficacy of monophasic and biphasic waveforms for transthoracic cardioversion of atrial fibrillation and atrial flutter. Am Heart J 2005; 149:316.
  16. Tieleman RG, De Langen C, Van Gelder IC, et al. Verapamil reduces tachycardia-induced electrical remodeling of the atria. Circulation 1997; 95:1945.
  17. De Simone A, Stabile G, Vitale DF, et al. Pretreatment with verapamil in patients with persistent or chronic atrial fibrillation who underwent electrical cardioversion. J Am Coll Cardiol 1999; 34:810.
  18. Mann DL, Maisel AS, Atwood JE, et al. Absence of cardioversion-induced ventricular arrhythmias in patients with therapeutic digoxin levels. J Am Coll Cardiol 1985; 5:882.
  19. Alam M, Thorstrand C. Left ventricular function in patients with atrial fibrillation before and after cardioversion. Am J Cardiol 1992; 69:694.
  20. Fatkin D, Kuchar DL, Thorburn CW, Feneley MP. Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for "atrial stunning" as a mechanism of thromboembolic complications. J Am Coll Cardiol 1994; 23:307.
  21. Van Gelder IC, Crijns HJ, Van Gilst WH, et al. Prediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current electrical cardioversion of chronic atrial fibrillation and flutter. Am J Cardiol 1991; 68:41.
  22. Tieleman RG, Van Gelder IC, Crijns HJ, et al. Early recurrences of atrial fibrillation after electrical cardioversion: a result of fibrillation-induced electrical remodeling of the atria? J Am Coll Cardiol 1998; 31:167.
  23. Bertaglia E, D'Este D, Zerbo F, et al. Success of serial external electrical cardioversion of persistent atrial fibrillation in maintaining sinus rhythm; a randomized study. Eur Heart J 2002; 23:1522.
  24. Van Gelder IC, Crijns HJ, Tieleman RG, et al. Chronic atrial fibrillation. Success of serial cardioversion therapy and safety of oral anticoagulation. Arch Intern Med 1996; 156:2585.
  25. Grönberg T, Nuotio I, Nikkinen M, et al. Arrhythmic complications after electrical cardioversion of acute atrial fibrillation: the FinCV study. Europace 2013; 15:1432.
  26. Saksena S, Prakash A, Hill M, et al. Prevention of recurrent atrial fibrillation with chronic dual-site right atrial pacing. J Am Coll Cardiol 1996; 28:687.
  27. Capucci A, Lenzi T, Boriani G, et al. Effectiveness of loading oral flecainide for converting recent-onset atrial fibrillation to sinus rhythm in patients without organic heart disease or with only systemic hypertension. Am J Cardiol 1992; 70:69.
  28. Alboni P, Botto GL, Baldi N, et al. Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach. N Engl J Med 2004; 351:2384.
  29. Alp NJ, Bell JA, Shahi M. Randomised double blind trial of oral versus intravenous flecainide for the cardioversion of acute atrial fibrillation. Heart 2000; 84:37.
  30. Stroobandt R, Stiels B, Hoebrechts R. Propafenone for conversion and prophylaxis of atrial fibrillation. Propafenone Atrial Fibrillation Trial Investigators. Am J Cardiol 1997; 79:418.
  31. Conti A, Del Taglia B, Mariannini Y, et al. Management of patients with acute atrial fibrillation in the ED. Am J Emerg Med 2010; 28:903.
  32. Khan IA. Single oral loading dose of propafenone for pharmacological cardioversion of recent-onset atrial fibrillation. J Am Coll Cardiol 2001; 37:542.
  33. Botto GL, Bonini W, Broffoni T, et al. Conversion of recent onset atrial fibrillation with single loading oral dose of propafenone: is in-hospital admission absolutely necessary? Pacing Clin Electrophysiol 1996; 19:1939.
  34. Bianconi L, Mennuni M, Lukic V, et al. Effects of oral propafenone administration before electrical cardioversion of chronic atrial fibrillation: a placebo-controlled study. J Am Coll Cardiol 1996; 28:700.
  35. Ellenbogen KA, Stambler BS, Wood MA, et al. Efficacy of intravenous ibutilide for rapid termination of atrial fibrillation and atrial flutter: a dose-response study. J Am Coll Cardiol 1996; 28:130.
  36. Stambler BS, Wood MA, Ellenbogen KA, et al. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Ibutilide Repeat Dose Study Investigators. Circulation 1996; 94:1613.
  37. Abi-Mansour P, Carberry PA, McCowan RJ, et al. Conversion efficacy and safety of repeated doses of ibutilide in patients with atrial flutter and atrial fibrillation. Study Investigators. Am Heart J 1998; 136:632.
  38. Volgman AS, Carberry PA, Stambler B, et al. Conversion efficacy and safety of intravenous ibutilide compared with intravenous procainamide in patients with atrial flutter or fibrillation. J Am Coll Cardiol 1998; 31:1414.
  39. Stambler BS, Wood MA, Ellenbogen KA. Antiarrhythmic actions of intravenous ibutilide compared with procainamide during human atrial flutter and fibrillation: electrophysiological determinants of enhanced conversion efficacy. Circulation 1997; 96:4298.
  40. Vos MA, Golitsyn SR, Stangl K, et al. Superiority of ibutilide (a new class III agent) over DL-sotalol in converting atrial flutter and atrial fibrillation. The Ibutilide/Sotalol Comparator Study Group. Heart 1998; 79:568.
  41. Patsilinakos S, Christou A, Kafkas N, et al. Effect of high doses of magnesium on converting ibutilide to a safe and more effective agent. Am J Cardiol 2010; 106:673.
  42. Singh S, Zoble RG, Yellen L, et al. Efficacy and safety of oral dofetilide in converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter: the symptomatic atrial fibrillation investigative research on dofetilide (SAFIRE-D) study. Circulation 2000; 102:2385.
  43. Greenbaum RA, Campbell TJ, Channer KS, et al. Conversion of atrial fibrillation and maintenance of sinus rhythm by dofetilide. The EMERALD (European and Australian Multicenter Evaluative Research on Atrial Fibrillation Dofetilide) study (Abstr). Circulation 1998; 98(17 Suppl): 1633.
  44. Banchs JE, Wolbrette DL, Samii SM, et al. Efficacy and safety of dofetilide in patients with atrial fibrillation and atrial flutter. J Interv Card Electrophysiol 2008; 23:111.
  45. Mounsey JP, DiMarco JP. Cardiovascular drugs. Dofetilide. Circulation 2000; 102:2665.
  46. Abraham JM, Saliba WI, Vekstein C, et al. Safety of oral dofetilide for rhythm control of atrial fibrillation and atrial flutter. Circ Arrhythm Electrophysiol 2015; 8:772.
  47. Vietti-Ramus G, Veglio F, Marchisio U, et al. Efficacy and safety of short intravenous amiodarone in supraventricular tachyarrhythmias. Int J Cardiol 1992; 35:77.
  48. Noc M, Stajer D, Horvat M. Intravenous amiodarone versus verapamil for acute conversion of paroxysmal atrial fibrillation to sinus rhythm. Am J Cardiol 1990; 65:679.
  49. Galve E, Rius T, Ballester R, et al. Intravenous amiodarone in treatment of recent-onset atrial fibrillation: results of a randomized, controlled study. J Am Coll Cardiol 1996; 27:1079.
  50. Camm AJ, Capucci A, Hohnloser SH, et al. A randomized active-controlled study comparing the efficacy and safety of vernakalant to amiodarone in recent-onset atrial fibrillation. J Am Coll Cardiol 2011; 57:313.
  51. Martínez-Marcos FJ, García-Garmendia JL, Ortega-Carpio A, et al. Comparison of intravenous flecainide, propafenone, and amiodarone for conversion of acute atrial fibrillation to sinus rhythm. Am J Cardiol 2000; 86:950.
  52. Peuhkurinen K, Niemelä M, Ylitalo A, et al. Effectiveness of amiodarone as a single oral dose for recent-onset atrial fibrillation. Am J Cardiol 2000; 85:462.
  53. Blanc JJ, Voinov C, Maarek M. Comparison of oral loading dose of propafenone and amiodarone for converting recent-onset atrial fibrillation. PARSIFAL Study Group. Am J Cardiol 1999; 84:1029.
  54. Singh BN, Singh SN, Reda DJ, et al. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 2005; 352:1861.
  55. Tieleman RG, Gosselink AT, Crijns HJ, et al. Efficacy, safety, and determinants of conversion of atrial fibrillation and flutter with oral amiodarone. Am J Cardiol 1997; 79:53.
  56. Kowey PR, Dorian P, Mitchell LB, et al. Vernakalant hydrochloride for the rapid conversion of atrial fibrillation after cardiac surgery: a randomized, double-blind, placebo-controlled trial. Circ Arrhythm Electrophysiol 2009; 2:652.
  57. Vardas PE, Kochiadakis GE, Igoumenidis NE, et al. Amiodarone as a first-choice drug for restoring sinus rhythm in patients with atrial fibrillation: a randomized, controlled study. Chest 2000; 117:1538.
  58. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199.
  59. Clemo HF, Wood MA, Gilligan DM, Ellenbogen KA. Intravenous amiodarone for acute heart rate control in the critically ill patient with atrial tachyarrhythmias. Am J Cardiol 1998; 81:594.
  60. Naccarelli GV, Wolbrette DL, Samii S, et al. Vernakalant--a promising therapy for conversion of recent-onset atrial fibrillation. Expert Opin Investig Drugs 2008; 17:805.
  61. Roy D, Pratt CM, Torp-Pedersen C, et al. Vernakalant hydrochloride for rapid conversion of atrial fibrillation: a phase 3, randomized, placebo-controlled trial. Circulation 2008; 117:1518.
  62. Müssigbrodt A, John S, Kosiuk J, et al. Vernakalant-facilitated electrical cardioversion: comparison of intravenous vernakalant and amiodarone for drug-enhanced electrical cardioversion of atrial fibrillation after failed electrical cardioversion. Europace 2016; 18:51.
  63. Ferreira E, Sunderji R, Gin K. Is oral sotalol effective in converting atrial fibrillation to sinus rhythm? Pharmacotherapy 1997; 17:1233.
  64. Chevalier P, Durand-Dubief A, Burri H, et al. Amiodarone versus placebo and class Ic drugs for cardioversion of recent-onset atrial fibrillation: a meta-analysis. J Am Coll Cardiol 2003; 41:255.
  65. Reisinger J, Gatterer E, Heinze G, et al. Prospective comparison of flecainide versus sotalol for immediate cardioversion of atrial fibrillation. Am J Cardiol 1998; 81:1450.
  66. Iannone P, Haupt E, Flego G, et al. Dronedarone for atrial fibrillation: the limited reliability of clinical practice guidelines. JAMA Intern Med 2014; 174:625.
  67. Intravenous digoxin in acute atrial fibrillation. Results of a randomized, placebo-controlled multicentre trial in 239 patients. The Digitalis in Acute Atrial Fibrillation (DAAF) Trial Group. Eur Heart J 1997; 18:649.
  68. Roberts SA, Diaz C, Nolan PE, et al. Effectiveness and costs of digoxin treatment for atrial fibrillation and flutter. Am J Cardiol 1993; 72:567.
  69. Anderson S, Blanski L, Byrd RC, et al. Comparison of the efficacy and safety of esmolol, a short-acting beta blocker, with placebo in the treatment of supraventricular tachyarrhythmias. The Esmolol vs Placebo Multicenter Study Group. Am Heart J 1986; 111:42.
  70. Waxman HL, Myerburg RJ, Appel R, Sung RJ. Verapamil for control of ventricular rate in paroxysmal supraventricular tachycardia and atrial fibrillation or flutter: a double-blind randomized cross-over study. Ann Intern Med 1981; 94:1.
  71. Salerno DM, Dias VC, Kleiger RE, et al. Efficacy and safety of intravenous diltiazem for treatment of atrial fibrillation and atrial flutter. The Diltiazem-Atrial Fibrillation/Flutter Study Group. Am J Cardiol 1989; 63:1046.
  72. Farshi R, Kistner D, Sarma JS, et al. Ventricular rate control in chronic atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimens. J Am Coll Cardiol 1999; 33:304.
  73. Camm AJ, Lip GY, De Caterina R, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33:2719.
  74. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESCEndorsed by the European Stroke Organisation (ESO). Eur Heart J 2016.
  75. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:2071.