How to Optimize Cardioversion of Atrial Fibrillation

Cardioversion (CV) is an essential component of rhythm control strategy in the treatment of atrial fibrillation (AF). Timing of CV is an important manageable factor in optimizing the safety and efficacy of CV. Based on observational studies, the success rate of CV seems to be best (approximate to 95%) at 12-48 h after the onset of arrhythmic symptoms compared with a lower success rate of approximate to 85% in later elective CV. Early AF recurrences are also less common after acute CV compared with later elective CV. CV causes a temporary increase in the risk of thromboembolic complications. Effective anticoagulation reduces this risk, especially during the first 2 weeks after successful CV. However, even during therapeutic anticoagulation, each elective CV increases the risk of stroke 4-fold (0.4% vs. 0.1%) during the first month after the procedure, compared with acute (<48 h) CV or avoiding CV. Spontaneous CVs are common during the early hours of AF. The short wait-and-see approach, up to 24-48 h, is a reasonable option for otherwise healthy but mildly symptomatic patients who are using therapeutic anticoagulation, since they are most likely to have spontaneous rhythm conversion and have no need for active CV. The probability of early treatment failure and antiarrhythmic treatment options should be evaluated before proceeding to CV to avoid the risks of futile CVs.

Automated summary

Cardioversion is an important strategy in the treatment of atrial fibrillation, and the timing of the procedure is crucial for its success and safety. Early cardioversion has a higher success rate and lower risk of early recurrences compared to later elective cardioversion. However, cardioversion does increase the risk of thromboembolic complications, which can be reduced with effective anticoagulation. Even with therapeutic anticoagulation, each elective cardioversion still carries a higher risk of stroke compared to acute cardioversion or avoiding cardioversion. For otherwise healthy patients on therapeutic anticoagulation, a short wait-and-see approach may be a reasonable option.