Acute Management of Atrial Fibrillation: Part I. Rate and Rhythm Control

American Family Physician,  July 15, 2002  by Dana E. King,  Lori M. Dickerson,  Jonathan L. Sack

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An alternative approach for achieving earlier return to sinus rhythm is early electrical cardioversion and the use of transesophageal echocardiography according to American Heart Association guidelines.(7) Transesophageal echocardiography is used to detect thrombi in the right atrium. If no thrombi are present, electrical cardioversion can be performed immediately; if thrombi are detected, cardioversion can be delayed until patients have undergone three weeks of oral anticoagulation using warfarin.(21) One recent comparative study(22) found no differences in thromboembolic complications between conventional treatment and early cardioversion following transesophageal echocardiography.

Because of the risk of complications such as heart failure and embolic stroke, restoration of sinus rhythm is thought to be preferable to allowing atrial fibrillation to continue. However, restoration of sinus rhythm is not always possible. In elderly patients with longstanding atrial fibrillation, repeated attempts at cardioversion may be counterproductive. The chances of reverting to and maintaining sinus rhythm are lower with longer duration of atrial fibrillation and decrease to particularly low levels when atrial fibrillation has been present for more than one year. When cardioversion is inappropriate or unsuccessful, medication should be used for ventricular rate control, and anticoagulation therapy should be considered.

General recommendations for the initial management of atrial fibrillation are summarized in Table 2.(2,3,7,8,22)

TABLE 2

General Recommendations for Initial Management of Atrial Fibrillation

Acute control of the ventricular rate is best achieved with an intravenously administered calcium channel blocker (e.g., diltiazem [Cardizem]) or beta blocker (e.g., esmolol [Brevibloc]).

Immediate electrical cardioversion should be considered in hemodynamically unstable patients with atrial fibrillation.

Medical (pharmacologic) or electrical cardioversion following anticoagulation should be considered in hemodynamically stable patients with atrial fibrillation.

Elective electrical cardioversion should be used in patients with persistent or recurrent atrial fibrillation. The success rate for electrical cardioversion is 90%.

Medical cardioversion is a convenient and reasonable alternative in some patients, but it does not always terminate atrial fibrillation. The success rate for medical cardioversion is about 40%.

Early cardioversion after transesophageal echocardiography with intravenous anticoagulation is an increasingly used alternative strategy.

Information from references 2, 3, 7, 8, and 22.

The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.

Members of various family practice departments develop articles for "Practical Therapeutics." This article is one in a series coordinated by the Department of Family Medicine at the Medical University of South Carolina. Guest editor of the series is William J. Hueston, M.D.