After successful cardioversion, anticoagulation therapy should continue for at least 1 month to decrease the risk for thromboembolism, which may occur from the formation of a mural thrombus. After cardioversion is done and the patient's AF reverts to a sinus rhythm, use of daily outpatient antiarrhythmic drugs is not typically recommended, as these drugs have associated risks; therefore, they should be taken only when patients have persistent or frequently recurring symptoms.
Antiarrhythmic drugs that can be used to convert AF to a normal sinus rhythm include ibutilide, flecainide, procainamide, and amiodarone. Each has different risks, success rates, and indications, based on the duration of AF. As a group, antiarrhythmic drugs can convert 30%-60% of cases of AF to a normal sinus rhythm. Electrical cardioversion has a higher success rate, converting 75%-95% of AF cases to normal sinus rhythm.
Electrical cardioversion may be done in a nonemergency setting after 4 weeks of anticoagulation treatment to decrease the risk for thromboembolism, or it can be done after transesophageal echocardiography has ruled out a left atrial or appendage thrombus. It may be required on an emergency basis in a hemodynamically unstable patient. In this situation, AF often has an acute onset, and the benefits of cardioversion outweigh the risks for thromboembolism.
The role of cardioversion to manage AF in the emergency department is an emerging one. Patients who are at low risk, are clinically stable, and present to the emergency department with new-onset AF can be treated with chemical or electrical cardioversion and safely discharged home, with close follow-up by a primary physician or cardiologist.
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