Cardioversion

consider cardioversion if

• If AF >48 h 2–5% risk stroke w/ cardioversion (pharmacologic or electric) ∴ either TEE to r/o thrombus or ensure therapeutic anticoagulation ≥3 wk prior
• If needs to cardiovert urgently, often anticoagulate acutely (eg, IV UFH)

For AF <36 hrs

• no Δ in % in SR at 4 wks w/ early cardioversion vs. wait & see (βb + a/c), with spont cardioversion in 69% and cardioversion required in 28% (NEJM 2019;380:1499)
• Likelihood of success ∝ AF duration & atrial size; control precipitants (eg, vol status, thyroid)
• Before electrical cardiovert, consider pre- Rx w/ AAD (eg, ibutilide), esp. if 1st cardiovert failed
• For pharmacologic cardioversion, class III and IC drugs have best proven efficacy
• If SR returns (spont. or w/ Rx), atria may be mech. stunned; also, high risk of recurrent AF over next 3 mo. ∴ Anticoag postcardioversion ≥4 wk (? unless AF <48 h and low risk).