Atrial Fibrillation - ED Electrical and Pharmacologic Cardioversion Protocol

1

General Measures:

If unstable: proceed more urgently – see emergent cardioversion protocol

Ensure atrial fibrillation of recent onset (<48 hours) and not recurrent

NPO for at least 3-4 hrs, bedrest, IV, monitor Work up:

Troponin, electrolytes, TSH, CMP, PT/INR, PTT, BNP

Echocardiogram to be arranged if not previously obtained

TEE in selected cases for rapid cardioversion if unknown duration or AFib > 48hrs

Assess CHADVASC score and document in chart

Management: Control rate; consider rhythm cardioversion, and anticoagulate as shown below, according to Category: 1, 2 or 3 Category 1. Normal EF

Rate control: Ca-blocker or beta-blocker.

Cardiovert: o If onset < 48 hours, consider DC cardioversion OR with one of the following agents: amiodarone, ibutilide,

procainamide, (flecainide, propafenone), sotalol. o If onset > 48 hours: avoid drugs that may cardiovert (e.g. amiodarone). Either:

Delayed Cardioversion: anticoagulate adequately x 3 weeks, then cardioversion, then anticoagulate x 4 weeks

Early Cardioversion: admission, iv heparin, then TEE, then cardioversion within 24 hours, then anticoagulate x 4 weeks

Anticoagulate if not contraindicated, if A fib > 48 hrs

Category 2. EF< 40% or CHF

Rate control: o digoxin, diltiazem, amiodarone (avoid if onset of AF > 48 hours). o avoid verapamil, beta-blockers, ibutilide, procainamide (and propafenone/flecainide)

Cardiovert: same as Category 1, except the only conversion agent allowed is amiodarone.

Anticoagulate, if A fib > 48 hr.

Category 3. WPW A fib

Suggested by: delta wave on resting EKG, very young patient, HR>300

Avoid adenosine, beta-blocker, Ca-blocker, or Digoxin

If < 48 hour: o If EF normal: one of the following for both rate control and cardioversion: amiodarone, procainamide,

propafenone, sotalol, flecainide o If EF abnormal or CHF: amiodarone or cardioversion

If > 48 hour o Medication listed above may be associated with risk of emboli o Anticoagulate and DC cardioversion as in Category 1.

Note: new ALCS does not allow mixing antiarrhythmics for AFib/flutter.

Atrial Fibrillation - ED Electrical and Pharmacologic Cardioversion Protocol

2

Electrical Cardioversion

[stable pt with a tachydysrhythmia (rapid atrial fibrillation, supraventricular tachycardia/SVT, ventricular tachycardia/VT with a

pulse)]:

1. Properly place on monitor/defibrillation that is capable of providing synchronization. Apply patches anteroposterior.

2. RE-assess cardiac rhythm for appropriateness of cardioversion

3. Have equipment available /prepared for possible worsening of patient’s condition

4. Anesthesia present if possible and non-urgent/IV sedation/Airway management

5. Ensure all personnel are clear of patient before initiating chock

6. Apply synchronization –assure sensing or R wave (and not T wave)

7. Synchronized shock: refer to ACLS and AHA guidelines below:

8. Reassess

o If no response to cardioversion, can repeat steps above up to 3 shocks, provider can recommend an increase in

joules. REMEMBER TO RE-SYNCRONIZE EACH TIME. If pulseless, begin BLS/ACLS protocols for cardiac arrest. If

rhythm stabilized, recover

9. Provider anticoagulation

o Recommend 4 weeks of anticoagulation after cardioversion

Consider: warfarin, dabigatran, rivaroxaban, apixaban or edoxaban

After 4 weeks, utilize CHADSVAASC scoring for need of long-term anticoagulation

10. Discharge

o Home after 1-2 hours of observation post procedure

o Discharge home on rate control medication

o Arrange for follow up with cardiology or primary care in 1 week with suggestion for outpt echocardiogram if not

completed prior

Neumar RW, Shuster M, Callaway CW, et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S315.