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Pharmacological Cardioversion of Atrial Fibrillation

Current Management and Treatment Options

  • Therapy In Practice
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Abstract

Atrial fibrillation (AF) is the most common form of arrhythmia, carrying high social costs. It is usually first seen by general practitioners or in emergency departments. Despite the availability of consensus guidelines, considerable variations exist in treatment practice, especially outside specialised cardiological settings. Cardioversion to sinus rhythm aims to: (i) restore the atrial contribution to ventricular filling/output; (ii) regularise ventricular rate; and (iii) interrupt atrial remodelling. Cardioversion always requires careful assessment of potential proarrhythmic and thromboembolic risks, and this translates into the need to personalise treatment decisions. Among the many clinical variables that affect strategy selection, time from onset is crucial.

In selected patients, pharmacological cardioversion of recent-onset AF can be a safely used, feasible and effective approach, even in internal medicine and emergency departments. In most cases of recent-onset AF, pharmacological cardioversion provides an important- and probably more cost effective-alternative to electrical cardioversion, which can then be employed as a second-line therapy for nonresponders.

Class IC agents (flecainide or propafenone), which can be safely used in hospitalised patients with recent-onset AF without left ventricular dysfunction, can provide rapid conversion to sinus rhythm after either intravenous administration or oral loading. Although intravenous amiodarone requires longer conversion times, it is still the standard treatment for patients with heart failure. Ibutilide also provides good conversion rates and could be used for AF patients with left ventricular dysfunction (were it not for high costs).

For long-lasting AF most pharmacological treatments have only limited efficacy and electrical cardioversion remains the gold standard in this setting. However, a widely used strategy involves pretreatment with amiodarone in the weeks before planned electrical cardioversion: this provides optimal prophylaxis and can sometimes even restore sinus rhythm. Dofetilide may also be capable of restoring sinus rhythm in up to 25–30% of patients and can be used in patients with heart failure.

The potential risk of proarrhythmia increases the need for careful therapeutic decision making and management of pharmacological cardioversion. The results of recent trials (AFFIRM [Atrial Fibrillation Follow-up Investigation of Rhythm Management] and RACE [Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation]) on rate versus rhythm control strategies in the long term have led to a generalised shift in interest towards rate control. Although carefully designed studies are required to better define the role of pharmacological rhythm control in specific AF settings, this alternative option remains a recommendable strategy for many patients, especially those in acute care.

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Acknowledgements

The authors are grateful to their librarian, Claudia Cavicchi, for constant bibliographic assistance and to Robin M.T. Cooke for scientific editing. No sources of founding were used to assist in the preparation of this manuscript. The authors have no conflicts of interest that are directly relevant to the content of this review.

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  1. Institute of Cardiology, University of Bologna, Azienda Ospedaliera S. Orsola-Malpighi, Via Massarenti 9, Bologna, 40138, Italy

    Giuseppe Boriani, Igor Diemberger, Mauro Biffi, Cristian Martignani & Angelo Branzi

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  1. Giuseppe Boriani
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  2. Igor Diemberger
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  3. Mauro Biffi
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Correspondence to Giuseppe Boriani.

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Boriani, G., Diemberger, I., Biffi, M. et al. Pharmacological Cardioversion of Atrial Fibrillation. Drugs 64, 2741–2762 (2004). https://doi.org/10.2165/00003495-200464240-00003

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