Cardioversion Curriculum. Learning Objectives At the conclusion of this activity, the learner will...

Cardioversion Curriculum

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Learning Objectives

At the conclusion of this activity, the learner will be able to:

• Identify appropriate anticoagulation strategies prior to and following cardioversion.

• Provide anticoagulation therapy for the appropriate period before and after cardioversion.

• Determine appropriate antiarrhythmic drug therapy to restore sinus rhythm in patients who have AF of greater than or less than 7 days.

• Administer antiarrhythmic drug therapy to prevent ERAF after cardioversion.

• Recognize that administration of antiarrythmic medication prior to cardioversion may promote restoration of sinus rhythm and the implications with respect to thromboembolism.

• Recognize the different methods of cardioversion as well as both pre- and post-procedure anticoagulation strategies and anti-arrhythmic drug management.

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Candidates for Elective Cardioversion

• Patients with a reasonable expectation to remain in sinus rhythm

• Patients with substantial symptoms in AF with good rate control

• Patients in whom the physician considers sinus rhythm the preferred treatment strategy

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Special Considerations for Anticoagulation Prior to Cardioversion

• For patients with AF > 48 hours of AF, or when duration is unknown, 3 weeks of anticoagulation are required prior to cardioversion.

• Documentation of anticoagulation adequacy is important prior to cardioversion

• It may take longer than 3 weeks to achieve 3 consecutive weeks of adequate anticoagulation

• Anticoagulation must be continued for at least 4 weeks post cardioversion

• TEE can be used to assess LA for thrombus as alternative to 3-week anticoagulation (however, anti-coagulation must continue for 4 weeks post cardioversion

Fuster et al. J Amer Coll Cardiol 2006; 48: 854-906

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Prospective Companion of TEE-guided vs.Conventional-treatment Cardioversion of A. Fib

Klein AL, N Engl J Med 2001; 344: 1411-20 Atrial fibrillation > 2 days’ duration, Atrial fibrillation > 2 days’ duration, DC cardioversion prescribedDC cardioversion prescribed

Atrial fibrillation > 2 days’ duration, Atrial fibrillation > 2 days’ duration, DC cardioversion prescribedDC cardioversion prescribed

Random assignment (1:1)Random assignment (1:1)Random assignment (1:1)Random assignment (1:1)

Conventional treatment Conventional treatment groupgroup

Conventional treatment Conventional treatment groupgroup

Transesophageal-Transesophageal-echocardiography groupechocardiography group

Transesophageal-Transesophageal-echocardiography groupechocardiography group

Warfarin for 3 wkWarfarin for 3 wkWarfarin for 3 wkWarfarin for 3 wk

DC cardioversionDC cardioversionDC cardioversionDC cardioversion


No thrombus detectedNo thrombus detectedDC cardioversionDC cardioversion

No thrombus detectedNo thrombus detectedDC cardioversionDC cardioversion

Thrombus detectedThrombus detectedNo DC cardioversionNo DC cardioversionThrombus detectedThrombus detected

No DC cardioversionNo DC cardioversion



No thrombusNo thrombusDC cardioversionDC cardioversion

No thrombusNo thrombusDC cardioversionDC cardioversion

ThrombusThrombusNo DC cardioversionNo DC cardioversion

ThrombusThrombusNo DC cardioversionNo DC cardioversion

Warfarin for 4 wkWarfarin for 4 wkWarfarin for 4 wkWarfarin for 4 wk Warfarin for 4 wkWarfarin for 4 wkWarfarin for 4 wkWarfarin for 4 wk

Repeated transesophagealRepeated transesophagealechocardiographyechocardiography

Repeated transesophagealRepeated transesophagealechocardiographyechocardiography

Follow-up examinationFollow-up examination8 wk after assignment8 wk after assignmentFollow-up examinationFollow-up examination8 wk after assignment8 wk after assignment

Therapeutic anticoagulation Therapeutic anticoagulation with heparin or warfarinwith heparin or warfarin

Therapeutic anticoagulation Therapeutic anticoagulation with heparin or warfarinwith heparin or warfarin

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Clinical Outcomes of TEE-guided vs. Conventional-treatment Cardioversion of A. Fib

Variable TEE Guided (n= 619) Conventional Treatment (n=603)

Successful Cardioversion (%) 80.3 79.9

Time to Cardioversion (d) 3.0 + 5.6* 30.6 + 10.6

Embolic Events (%) 5 (0.8%) 3 (0.5%)

Hemorrhagic events (%) 18 (2.9%)* 33 (5.5%)

Death (%) 15 (2.4%) 6 (1.0%)

SR at 8 wks (%) 52.7 50.4

6

*significant

Klein AL, N Engl J Med 2001; 344: 1411-20

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Daily Incidence of AF Relapse After Electrical Cardioversion

Tieleman RG et al. J Am Coll Cardiol 1998; 31: 167-73

0 5 10 15 20 25 30 35

6

5

4

3

2

1

0

Num

ber

of p

atie

nts

with

rel

apse

of

AF

Days post cardioversion

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Procedural Aspects of Direct-current Cardioversion of Atrial Fibrillation

• Ensure appropriate anticoagulation

• Use adequate general anesthesia in fasting state

• Electrodes positioned anterior-posterior or anterior-lateral

• Confirm R-wave synchronization

• Biphasic shock waveform preferable

• Determine the need for pretreatment with antiarrhythmic drugs

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Cumulative Success in Cardioversion of A. Fib:Biphasic vs. Monophasic Waveform

Page RL et al. Page RL et al. J Am Coll CardiolJ Am Coll Cardiol 2002; 39: 1956-63 2002; 39: 1956-63

1.0

0.8

0.6

0.4

0.2

0.0

1.0

0.8

0.6

0.4

0.2

0.0

Monophasic

Biphasic

Monophasic

Biphasic

Pro

port

ion,

with

95%

Con

fiden

ce I

nter

val

Pro

port

ion,

with

95%

Con

fiden

ce I

nter

val

1st Shock 1-2 Shocks 1-3 Shocks 1-4 Shocks1st Shock 1-2 Shocks 1-3 Shocks 1-4 Shocks

**

*

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Recommendations for Direct-current Cardioversion of Atrial FibrillationClass I

1. When a rapid ventricular response does not respond promptly to pharmacological measures for patients with AF with ongoing myocardial ischemia, symptomatic hypotension, angina, or HF, immediate R-wave synchronized direct-current cardioversion is recommended. (Level of Evidence: C)

2. Immediate direct-current cardioversion is recommended for patient with AF involving preexcitation when very rapid tachycardia or hemodynamic instability occurs. (Level of Evidence: B)

3. Cardioversion is recommended in patients without hemodynamic instability when symptoms of AF are unacceptable to the patient. In case of early relapse of AF after cardioversion, repeated direct-current cardioversion, repeated direct-current cardioversion attempts may be made following administration of antiarrhythmic medication.

(Level of Evidence: C)

ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246

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Recommendations for Direct-current Cardioversion of Atrial Fibrillation

Class IIa

1. Direct-current cardioversion can be useful to restore sinus rhythm as part of a long-term management strategy for patients with AF. (Level of Evidence: B)

2. Patient preference is a reasonable consideration in the selection of infrequently repeated cardioversions for the management of symptomatic or recurrent AF. (Level of Evidence: C)


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Recommendations for Direct-current Cardioversion of Atrial Fibrillation

Class III

1. Frequent repetition of direct-current cardioversion is not recommended for patients who have relatively short periods of sinus rhythm between relapses of AF after multiple cardioversion procedures despite prophylactic antiarrhythmic drug therapy. (Level of Evidence: C)

2. Electrical cardioversion is contraindicated in patients with digitalis toxicity or hypokalemia. (Level of Evidence: C)


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Pharmacological Cardioversion of Atrial Fibrillation< 7 days Duration

Drug Class of Recommendation (level of evidence)

Agents with proven efficacy

Dofetilide I (A)

Flecainide I (A)

Ibutilide I (A)

Propafenone I (A)

Amiodarone IIa (A)

Less effective or incompletely studied

Disopyramide IIb (B)

Procainamide IIb (B)

Quinidine IIb (B)

Should not be administered

Digoxin III (A)

Sotalol III (A)

15

Modified from: ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246

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Successful Conversion Rate of Atrial Fibrillation and Flutter with Intravenous Ibutilide vs. Procainamide

Volgman AS et al. J Am Coll Cardiol 1998; 31: 1414-19

100

80

60

40

20

0

100

80

60

40

20

0

Ibutilide

Procainamide

Ibutilide

Procainamide

Suc

cess

rat

e (%

)S

ucce

ss r

ate

(%)

Combined Flutter Fibrillation

*

**

***

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Success Rates of Conversion to Sinus Rhythm with Vernakalant Compared with Placebo

Roy D Circulation 2008; 117:1518-1525

60

50

40

30

20

10

0

60

50

40

30

20

10

0

Vernakalant

Placebo

Vernakalant

Placebo

Per

cent

age

Per

cent

age

Short-Duration AF Long-duration AF Overall Population

4.04.0

51.751.7

00

7.97.9

2.62.6

37.637.6

P<0.001P<0.001

P=0.09P=0.09

P<0.001P<0.001

(n=75) (n=145) (n=40) (n=76) (n=115) (n=221)(n=75) (n=145) (n=40) (n=76) (n=115) (n=221)

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Cumulative Success Rates of Conversion to Sinus Rhythm Over Time with Vernakalant vs. Placebo

0.6

0.5

0.4

0.3

0.2

0.1

0

0.6

0.5

0.4

0.3

0.2

0.1

0

Pro

port

ion

of P

atie

nts

with

C

onve

rsio

n to

SR

Pro

port

ion

of P

atie

nts

with

C

onve

rsio

n to

SR

0 20 40 60 80 1000 20 40 60 80 100Time from First Infusion of Study Drug (min.)Time from First Infusion of Study Drug (min.)

P<.001 (Log-Rank Test)P<.001 (Log-Rank Test)

Vernakalant

Placebo

Vernakalant

Placebo

Roy D Circulation 2008; 117:1518-1525

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Pharmacological Cardioversion of Atrial Fibrillation> 7 days Duration

Drug Class of Recommendation (level of evidence)

Agents with proven efficacy

Dofetilide I (A)

Amiodarone IIa (A)

Ibutilide IIa (A)

Less effective or incompletely studied

Disopyramide IIb (B)

Flecainide IIb (B)

Procainamide IIb (B)

Propafenone IIb (B)

Quinidine IIb (B)

Should not be administered

Digoxin III (B)

Sotalol III (B)

19

Modified from: ACC/AHA/ESC Practice Guidelines, Fuster et al. JACC 2006; 48: e149-246

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Outpatient Treatment of Recent-onset Atrial Fibrillation with the “Pill-in-the-Pocket” Approach

• 268 consecutive patients with recent-onset (< 48 hours) A. Fib with mean heart rate > 70/min and systolic BP > 100mmHg

• Patients treated in emergency room or cardiology ward

• Some exclusions: • Preexcitaiton; BB block; IHD; DCM; HCM;

• History of HF; prev AF > 7 days duration

• Single oral AA drug dose:• Flecainide 300mg (>70kg); 200mg (<70kg)

• Propafenone 600mg (>70kg); 450mg (<70kg)

• 58 (22%) patients excluded because of treatment failures or side effects (n=14)• hypotension (n=4); symptomatic bradycardia (n=3); transient A Fl (n=7)

Alboni P et al. N Engl J Med 2004; 351: 2384-91

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210 patients enrolled for 210 patients enrolled for out-of-hospital treatmentout-of-hospital treatment210 patients enrolled for 210 patients enrolled for out-of-hospital treatmentout-of-hospital treatment

58 patients excluded58 patients excluded- 3 patients (1%) met - 3 patients (1%) met echocardiographic echocardiographic

exclusion criteria exclusion criteria- 41 patients (15%) - 41 patients (15%) had drug inefficacy had drug inefficacy- 14 patients (5%) had - 14 patients (5%) had adverse effects adverse effects

58 patients excluded58 patients excluded- 3 patients (1%) met - 3 patients (1%) met echocardiographic echocardiographic

exclusion criteria exclusion criteria- 41 patients (15%) - 41 patients (15%) had drug inefficacy had drug inefficacy- 14 patients (5%) had - 14 patients (5%) had adverse effects adverse effects

4 patients (2%) lost to 4 patients (2%) lost to follow-upfollow-up

4 patients (2%) lost to 4 patients (2%) lost to follow-upfollow-up


268 patients treated 268 patients treated in hospitalin hospital

268 patients treated 268 patients treated in hospitalin hospital

41 patients (20%) had no 41 patients (20%) had no recurrencerecurrence

41 patients (20%) had no 41 patients (20%) had no recurrencerecurrence

165 patients (79%) had 165 patients (79%) had recurrencesrecurrences


“Pill-in-the-Pocket” Approach to Cardiovert A. Fib

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618 arrhythmic episodes618 arrhythmic episodes618 arrhythmic episodes618 arrhythmic episodes

49 untreated episodes (8%)49 untreated episodes (8%)49 untreated episodes (8%)49 untreated episodes (8%) 569 treated episodes (92%)569 treated episodes (92%)569 treated episodes (92%)569 treated episodes (92%)

5 episodes (10%) involved 5 episodes (10%) involved

ER contactER contact

5 episodes (10%) involved 5 episodes (10%) involved

ER contactER contact

534 episodes (94%) 534 episodes (94%) interrupted interrupted << 6 hr 6 hr

16 episodes (3%) interrupted 16 episodes (3%) interrupted > 6hr; did not contact ER> 6hr; did not contact ER

26 episodes (5%) involved 26 episodes (5%) involved ER contactER contact

534 episodes (94%) 534 episodes (94%) interrupted interrupted << 6 hr 6 hr

16 episodes (3%) interrupted 16 episodes (3%) interrupted > 6hr; did not contact ER> 6hr; did not contact ER

26 episodes (5%) involved 26 episodes (5%) involved ER contactER contact

Total of 31 episodes (5% Total of 31 episodes (5% involved ER contactinvolved ER contact

Total of 31 episodes (5% Total of 31 episodes (5% involved ER contactinvolved ER contact

“Pill-in-the-Pocket” Approach to Cardiovert A. Fib


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Recommendations for Pharmacological Cardioversion of Atrial Fibrillation

Class I

• Administration of flecainide, dofetilide, propafenone, or ibutilide is recommended for pharmacological cardioversion of AF. (Level of Evidence: A)


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Recommendations for Pharmacological Cardioversion of Atrial Fibrillation Class IIa

1. Administration of amiodarone is a reasonable option for pharmacological cardioversion of AF. (Level of Evidence: A)

2. A single oral bonus dose of propafenone or flecainide (“pill-in-the-pocket”) can be administered to terminate persistent AF outside the hospital once treatment has proved safe in a hospital for selected patients without sinus or AV node dysfunction, bundle-branch block,QT-interval prolongation, the Brugada syndrome, or structural heart disease. Before antiarrhythmic medication is initiated, a beta blocker or nondihydropyridine calcium channel antagonist should be given to prevent rapid AV conduction in the event atrial flutter occurs. (Level of Evidence: C)

3. Administration of amiodarone can be beneficial on an outpatient basis in patients with paroxysmal or persistent AF when rapid restoration of sinus rhythm is not deemed necessary. (Level of Evidence: C)


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Class IIb

• Administration of quinidine or procainamide might be considered for pharmacological cardioversion of AF, but the usefulness of these agents is not well established. (Level of Evidence: C)


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Class III

1. Digoxin and sotalol may be harmful when used for pharmacological cardioversion of AF and are not recommended. (Level of Evidence: A)

2. Quinidine, procainamide, disopyramide, and dofetilide should not be started out of hospital for conversion of AF to sinus rhythm. (Level of Evidence: B)


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