Bayer Pharma AG

Essence of this article

Electrical or pharmacological cardioversion is performed to attempt to re-establish a normal sinus rhythm in patients with non-valvular atrial fibrillation (AF). Electrical cardioversion is the preferred method for patients who present with persistent AF or those who are haemodynamically unstable. Stable patients or those with long-standing AF may receive either electrical or pharmacological cardioversion. Cardioversion success rates vary and AF will recur in approximately half of patients whose sinus rhythm is successfully normalized. Factors predicting the success of cardioversion are not well established but may include a shorter versus longer duration of AF. Duration and type of AF, concomitant diabetes and alcohol consumption may help to predict likely AF recurrence in patients who are successfully cardioverted.

Cardioversion in patients with atrial fibrillation

Given the medical, social and economic burden of atrial fibrillation (AF), correction of arrhythmia is desirable. Cardioversion is performed to attempt to re-establish a normal sinus rhythm in patients with AF,387 either by:

  • 'Stunning' the left atrium using an electrical pulse (electrical cardioversion)388 or
  • Using rate-modifying drugs (pharmacological cardioversion)388

The European Society of Cardiology (ESC) guidelines for the management of AF recommend:389, 390

  • Electrical cardioversion for patients who have recent-onset AF and are haemodynamically unstable
  • A choice between electrical and pharmacological cardioversion, based on patient and physician preference, in stable patients or those with persistent AF

European Society of Cardiology recommendations for cardioversion of recent-onset atrial fibrillation390

Reported success rates of cardioversion vary:388

  • >90% for electrical cardioversion
  • 40–70% for pharmacological cardioversion

Evidence regarding the factors that predict successful cardioversion is limited, but a shorter versus longer duration of AF was independently associated with success in several studies.{391–394} Lower body weight392 and pre-treatment with antiarrhythmic drugs393, 394 may also be associated with successful cardioversion, but evidence on the influence of age is conflicting.391, 394, 395

AF recurs within 1 year in approximately half of patients who undergo successful cardioversion.387 Factors that have been identified as potentially predictive of AF recurrence include decreased heart function,391 increased CHA2DS2-VASc score,396 age ≤65 years (rather than older), paroxysmal (rather than permanent) AF and alcohol consumption.393


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