Atrial fibrillation is a common cardiac rhythm disturbance and increases in prevalence with advancing age. Approximately 1% of patients with atrial fibrillation are less than 60 years of age, whereas up to 12% of patients are 75 to 84 years of age.
More than one third of patients with atrial fibrillation are greater than or equal to 80 years of age.
A) Direct-Current cardioversion
In pursuing a rhythm-control strategy, cardioversion is recommended for patients with atrial fibrillation or atrial flutter as a method to restore sinus rhythm. If cardioversion is unsuccessful, repeated direct-current cardioversion attempts may be made after adjusting the location of the electrodes or applying pressure over the electrodes, or following administration of an antiarrhythmic medication. ( Class I; Level of Evidence: B )
Cardioversion is recommended when a rapid ventricular response to atrial fibrillation or atrial flutter does not respond promptly to pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension, or heart failure. ( Class I; Level of Evidence: C )
Cardioversion is recommended for patients with atrial fibrillation or atrial flutter and pre-excitation when tachycardia is associated with hemodynamic instability. ( Class I; Level of Evidence: C ) 1. It is reasonable to perform repeated cardioversions in patients with persistent AF provided that sinus rhythm can be maintained for a clinically meaningful period between cardioversion procedures. Severity of AF symptoms and patient preference should be considered when embarking on a strategy requiring serial cardioversion procedures. ( Class IIa; Level of Evidence: C )
B) Pharmacological cardioversion
Flecainide, Dofetilide, Propafenone, and intravenous Ibutilide are useful for pharmacological cardioversion of atrial fibrillation or atrial flutter provided contraindications to the selected drug are absent. ( Class I; Level of Evidence: A )
Administration of oral Amiodarone is a reasonable option for pharmacological cardioversion of atrial fibrillation. ( Class IIa; Level of Evidence: A )
Propafenone or Flecainide ( pill-in-the-pocket ) in addition to a beta blocker or nondihydropyridine calcium channel antagonist is reasonable to terminate atrial fibrillation outside the hospital once this treatment has been observed to be safe in a monitored setting for selected patients. ( Class IIA; Level of Evidence: B )
Dofetilide therapy should not be initiated out of hospital owing to the risk of excessive QT prolongation that can cause torsades de pointes. ( Class III: Harm; Level of Evidence: B ) ( Xagena )
Source: AHA/ACC/HRS Atrial Fibrillation Guideline 2014