NHF guideline 2018.. 6.3.4.6 anticoagulation is recommended at the time of cardioversion, and for 4 weeks post procedurally strength of evidence strong but quality of evidence is low any comments?? Dr E S Krishnan Senior Consultant Emergency Medicine, Wyong District Hospital, NSW Australia
The ED literature is replete on Afib in that electrical cardioversion is safe if the arrhythmia is less than 48 hrs. In the non anti-coagulated, indications for a DOAC should be based on CHADS-2-VASC or another validated stroke risk stratification tool. It is not true in my read of the literature that the risk of stroke post cardioversion and restoration of SR = the risk of AF without restoration of SR. The risk of stroke is higher post restoration of SR in the patient in AF .... and much higher if the AF >48hrs and then restoration of SR. It's not just due to the AF, is the restoration of SR after AF that confers the risk of stroke.
The part on procedural sedation for AF cardioversion was confusing as well. The PS for AF should be very similar to PS for other short painful procedures. With a trained PS team, using ETCO2 and a pre-oxygenated patient. Use propofol (without or without fentanyl prior -- it is a very short procedure and most patients don't require analgesia) titrating to clinical effect. Giving adults ketamine alone is asking for emergence reactions which are very disturbing to them.
The risk of causing asystole with synchronized cardioversion would be exceedingly rare ... not sure why it was mentioned. And of course not cardioverting a symptomatic patient in AF <48 hrs and then needing to initiate rate control and a DOAC and then an ECHO guided approach to restoration of SR after a period of anti-coagulation is just kicking the problem down the road for the patient and exposing them to the risk of the meds and a period of medical tests and procedures. .
Adam - thanks for the comments. The truth is there's little actual data on the risk of stroke after cardioversion and many patients with PAF spontaneously flip back and forth. In Stiell's work on the aggressive Ottawa protocol, if I remember correctly, the only patient who had a stroke was one who wasn't actively converted in the ED but spontaneously converted. In terms of PSA, Josh and I both favor etomidate as our agent of choice - quick on, quick off and no titration. I've also used NO for this indication. Ketamine would be fine but I think it lasts too long. Propofol does seem to cause an increased risk of hypoventilation and loss of airway reflexes but usually so brief that it's easily managed. Asked Amal about the asystole issue. He pointed out that the point of cardioversion is to put patient's into a brief asystolic period almost as a reboot of the system. If the cardioversion is successful, they'll all have a brief asystole but, it's very brief. Longer periods are described but are exceedingly rare.
Thanks Anand -- not to belabour this point but at the time of reversion to SR whether electrical, pharmacologic or spontaneous there is a transient incremental increase in the rate of stroke from the baseline risk for patients in AF who are not in SR. Most embolic events occur within 10 days of reversion to SR. The risk is much higher if the duration of AF >48hrs or the duration of AF is unknown. Restoration of SR is safe and a good for patients if done <48 hrs and then DOAC if indicated. Some recommend DOAC x 3-4 weeks routinely post restoration of SR -- regardless of strole risk stratification -- but I don't and the research is not settled on this.
And to the asystole issue with synchronized cardioversion need to not conflate an EP phenomenon with a clinical outcome which of course are very different and the ladder exceptionally uncommon/unlikely.
Thanks for helping clarify some of this. After completing the EMRAP segment, the quoted equal risk of cardioversion to general AF stroke risk left me confused and would lead one to surmise that if one were to simply start anticoagulation and mitigate stroke risk, then really the duration of time in AF would be inconsequential. I figured there was a strong reason that cardiologists refuse to cardiovert patients without anticoagulation for at least a month.
That being said, I am aggressive with my cardioversion in patients in AF less than 48 hours and our cardiologists DO recommend 1 month of DOAC therapy after cardioversion. Interestingly, I did have a cardiologist tell me that if a patient spontaneously converts to SR, and goes BACK into AF, the clock restarts. This made no sense to me either.... imagine patient in pAF episode for 1 week, spontaneously back to SR in front of you, then falls back into pAF right before discharge?? Cardiologist says "don't worry, clock resets!" but really this patient has been in AF for 1 week with a 15 minute break in front of you.... I'm not cardioverting that patient despite what cardiologist thinks. They can do it tomorrow if THEY think it is safe.
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Easwaran K. - January 8, 2023 8:12 PM
NHF guideline 2018.. 6.3.4.6 anticoagulation is recommended at the time of cardioversion, and for 4 weeks post procedurally
strength of evidence strong but quality of evidence is low
any comments??
Dr E S Krishnan
Senior Consultant Emergency Medicine, Wyong District Hospital, NSW Australia
Joshua B. - January 10, 2023 1:34 PM
I rarely have patients without anticoagulation that I cardiovert, but I don't currently do this practice.
This guideline may change what I do
Thanks for the comments!
Adam O. - January 23, 2023 1:34 PM
The ED literature is replete on Afib in that electrical cardioversion is safe if the arrhythmia is less than 48 hrs. In the non anti-coagulated, indications for a DOAC should be based on CHADS-2-VASC or another validated stroke risk stratification tool. It is not true in my read of the literature that the risk of stroke post cardioversion and restoration of SR = the risk of AF without restoration of SR. The risk of stroke is higher post restoration of SR in the patient in AF .... and much higher if the AF >48hrs and then restoration of SR. It's not just due to the AF, is the restoration of SR after AF that confers the risk of stroke.
The part on procedural sedation for AF cardioversion was confusing as well. The PS for AF should be very similar to PS for other short painful procedures. With a trained PS team, using ETCO2 and a pre-oxygenated patient. Use propofol (without or without fentanyl prior -- it is a very short procedure and most patients don't require analgesia) titrating to clinical effect. Giving adults ketamine alone is asking for emergence reactions which are very disturbing to them.
The risk of causing asystole with synchronized cardioversion would be exceedingly rare ... not sure why it was mentioned. And of course not cardioverting a symptomatic patient in AF <48 hrs and then needing to initiate rate control and a DOAC and then an ECHO guided approach to restoration of SR after a period of anti-coagulation is just kicking the problem down the road for the patient and exposing them to the risk of the meds and a period of medical tests and procedures.
.
Anand S. - January 24, 2023 1:58 PM
Adam - thanks for the comments. The truth is there's little actual data on the risk of stroke after cardioversion and many patients with PAF spontaneously flip back and forth. In Stiell's work on the aggressive Ottawa protocol, if I remember correctly, the only patient who had a stroke was one who wasn't actively converted in the ED but spontaneously converted.
In terms of PSA, Josh and I both favor etomidate as our agent of choice - quick on, quick off and no titration. I've also used NO for this indication. Ketamine would be fine but I think it lasts too long. Propofol does seem to cause an increased risk of hypoventilation and loss of airway reflexes but usually so brief that it's easily managed.
Asked Amal about the asystole issue. He pointed out that the point of cardioversion is to put patient's into a brief asystolic period almost as a reboot of the system. If the cardioversion is successful, they'll all have a brief asystole but, it's very brief. Longer periods are described but are exceedingly rare.
Adam O. - January 25, 2023 12:07 PM
Thanks Anand -- not to belabour this point but at the time of reversion to SR whether electrical, pharmacologic or spontaneous there is a transient incremental increase in the rate of stroke from the baseline risk for patients in AF who are not in SR. Most embolic events occur within 10 days of reversion to SR. The risk is much higher if the duration of AF >48hrs or the duration of AF is unknown. Restoration of SR is safe and a good for patients if done <48 hrs and then DOAC if indicated. Some recommend DOAC x 3-4 weeks routinely post restoration of SR -- regardless of strole risk stratification -- but I don't and the research is not settled on this.
And to the asystole issue with synchronized cardioversion need to not conflate an EP phenomenon with a clinical outcome which of course are very different and the ladder exceptionally uncommon/unlikely.
Dane S. - February 12, 2023 1:30 AM
Thanks for helping clarify some of this. After completing the EMRAP segment, the quoted equal risk of cardioversion to general AF stroke risk left me confused and would lead one to surmise that if one were to simply start anticoagulation and mitigate stroke risk, then really the duration of time in AF would be inconsequential. I figured there was a strong reason that cardiologists refuse to cardiovert patients without anticoagulation for at least a month.
That being said, I am aggressive with my cardioversion in patients in AF less than 48 hours and our cardiologists DO recommend 1 month of DOAC therapy after cardioversion. Interestingly, I did have a cardiologist tell me that if a patient spontaneously converts to SR, and goes BACK into AF, the clock restarts. This made no sense to me either.... imagine patient in pAF episode for 1 week, spontaneously back to SR in front of you, then falls back into pAF right before discharge?? Cardiologist says "don't worry, clock resets!" but really this patient has been in AF for 1 week with a 15 minute break in front of you.... I'm not cardioverting that patient despite what cardiologist thinks. They can do it tomorrow if THEY think it is safe.