Canadian Journal of Cardiology
Viewpoint| Volume 35, ISSUE 10, P1296-1300, October 2019

Safe Cardioversion for Patients With Acute-Onset Atrial Fibrillation and Flutter: Practical Concerns and Considerations


      In this Viewpoint concerns raised by Canadian emergency physicians regarding recommendations 2 and 6 from the recent Canadian Cardiovascular Society 2018 update for atrial fibrillation are discussed. These recommendations narrow the window for safe cardioversion and suggest 4 weeks of anticoagulation for all patients who undergo urgent cardioversion regardless of their CHADS-65 status. We discuss the implications of Grading of Recommendations, Assessment, Development, and Evaluation weak recommendations on the basis of low-quality evidence.


      Il est question dans ce point de vue des préoccupations soulevées par des urgentologues canadiens concernant les recommandations 2 et 6 provenant de la récente mise à jour 2018 des lignes directrices de la Société canadienne de cardiologie en matière de fibrillation auriculaire. Ces recommandations réduisent la fenêtre pendant laquelle il est sûr d’effectuer une cardioversion et suggèrent l’administration d’un anticoaguant pendant 4 semaines à tous les patients qui subissent une cardioversion d’urgence, sans égard au score CHADS-65. Nous traitons de l’incidence qu’a la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation) à l’endroit des recommandations faibles reposant sur des données probantes de faible qualité.
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        • Andrade J.G.
        • Verma A.
        • Mitchell L.B.
        • et al.
        2018 Focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation.
        Can J Cardiol. 2018; 34: 1371-1392
        • Guyatt G.H.
        • Oxman A.D.
        • Vist G.E.
        • et al.
        GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
        BMJ. 2008; 336: 924-926
        • Airaksinen K.E.
        • Gronberg T.
        • Nuotio I.
        • et al.
        Thromboembolic complications after cardioversion of acute atrial fibrillation: the FinCV (Finnish CardioVersion) study.
        J Am Coll Cardiol. 2013; 62: 1187-1192
        • Nuotio I.
        • Hartikainen J.E.
        • Gronberg T.
        • et al.
        Time to cardioversion for acute atrial fibrillation and thromboembolic complications.
        JAMA. 2014; 312: 647-649
        • O’Reilly D.J.
        • Hopkins R.B.
        • Healey J.S.
        • et al.
        The burden of atrial fibrillation on the hospital sector in Canada.
        Can J Cardiol. 2013; 29: 229-235
        • Stiell I.G.
        • Clement C.M.
        • Rowe B.H.
        • et al.
        Outcomes for ED patients with recent-onset atrial fibrillation and flutter (RAFF) treated in Canadian hospitals.
        Ann Emerg Med. 2017; 69: 562-571
        • Scheuermeyer F.X.
        New frontiers in Canadian atrial fibrillation management.
        CJEM. 2018; 20: 323-324
        • Stiell I.G.
        • Scheuermeyer F.X.
        • Vadeboncoeur A.
        • et al.
        CAEP acute atrial fibrillation/flutter best practices checklist.
        Can J Emerg Med. 2018; 20: 334-342
        • Verma A.
        • Cairns J.A.
        • Mitchell L.B.
        • et al.
        2014 Focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation.
        Can J Cardiol. 2014; 30: 1114-1130
        • Scheuermeyer F.X.
        • Innes G.
        • Pourvali R.
        • et al.
        Missed opportunities for appropriate anticoagulation among emergency department patients with uncomplicated atrial fibrillation or flutter.
        Ann Emerg Med. 2013; 62: 557-565
        • Andrade J.G.
        • Mitchell L.B.
        Periprocedural anticoagulation for cardioversion of acute onset atrial fibrillation and flutter: evidence base for current guidelines.
        Can J Cardiol. 2019; 35: 1301-1310
        • Weigner M.J.
        • Caulfield T.A.
        • Danias P.G.
        • et al.
        Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting less than 48 hours.
        Ann Intern Med. 1997; 126: 615-620
        • Michael J.A.
        • Stiell I.G.
        • Agarwal S.
        • et al.
        Cardioversion of paroxysmal atrial fibrillation in the emergency department.
        Ann Emerg Med. 1999; 33: 379-387
        • Gallagher M.M.
        • Hennessy B.J.
        • Edvardsson N.
        • et al.
        Embolic complications of direct current cardioversion of atrial arrhythmias: association with low intensity of anticoagulation at the time of cardioversion.
        J Am Coll Cardiol. 2002; 40: 926-933
        • Burton J.H.
        • Vinson D.R.
        • Drummond K.
        • et al.
        Electrical cardioversion of emergency department patients with atrial fibrillation.
        Ann Emerg Med. 2004; 44: 20-30
        • Stiell I.G.
        • Clement C.M.
        • Perry J.J.
        • et al.
        An aggressive protocol for rapid management and discharge of emergency department patients with recent-onset episodes of atrial fibrillation and flutter.
        Can J Emerg Med. 2010; 12: 181-191
        • Scheuermeyer F.X.
        • Grafstein E.
        • Stenstrom R.
        • et al.
        Thirty-day outcomes of emergency department patients undergoing electrical cardioversion for atrial fibrillation or flutter.
        Acad Emerg Med. 2010; 17: 408-415
        • Pluymaekers N.A.H.A.
        • Dudink E.A.M.P.
        • Luermans J.G.L.M.
        • et al.
        Early or delayed cardioversion in recent-onset atrial fibrillation.
        N Engl J Med. 2019; 380: 1499-1508
        • Stiell I.G.
        • Macle L.
        Canadian Cardiovascular Society atrial fibrillation guidelines 2010: management of recent-onset atrial fibrillation and flutter in the emergency department.
        Can J Cardiol. 2011; 27: 38-46
        • Hellman T.
        • Kiviniemi T.
        • Nuotio I.
        • et al.
        Optimal timing for cardioversion in patients with atrial fibrillation.
        Clin Cardiol. 2018; 41: 966-971
        • Garg A.
        • Khunger M.
        • Seicean S.
        • et al.
        Incidence of thromboembolic complications within 30 days of electrical cardioversion performed within 48 hours of atrial fibrillation onset.
        JACC Clin Electrophysiol. 2016; 2: 487-494
        • Hansen M.L.
        • Jepsen R.M.
        • Olesen J.B.
        • et al.
        Thromboembolic risk in 16 274 atrial fibrillation patients undergoing direct current cardioversion with and without oral anticoagulant therapy.
        Europace. 2015; 17: 18-23
        • Sjalander S.
        • Svensson P.J.
        • Friberg L.
        Atrial fibrillation patients with CHA2DS2-VASc >1 benefit from oral anticoagulation prior to cardioversion.
        Int J Cardiol. 2016; 215: 360-363
      1. Scheuermeyer FX, Andolfatto G, Christenson J, et al. Electrical vs chemical cardioversion in patients with acute atrial fibrillation: a multicenter parallel group randomized controlled clinical trial. Acad Emerg Med, in press.

        • Stiell I.G.
        • Perry J.J.
        • Birnie D.
        • et al.
        A randomized controlled trial of drug vs electrical cardioversion for recent-onset atrial fibrillation (abstract).
        Acad Emerg Med. 2019; 26: S22
        • Neumann I.
        • Santesso N.
        • Akl E.A.
        • et al.
        A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach.
        J Clin Epidemiol. 2016; 72: 45-55
        • Stiggelbout A.M.
        • Van der Weijden T.
        • De Wit M.P.
        • et al.
        Shared decision making: really putting patients at the centre of healthcare.
        BMJ. 2012; 344: e256
        • Djulbegovic B.
        • Guyatt G.H.
        Evidence-based practice is not synonymous with delivery of uniform health care.
        JAMA. 2014; 312: 1293-1294

      Linked Article

      • Periprocedural Anticoagulation for Cardioversion of Acute Onset Atrial Fibrillation and Flutter: Evidence Base for Current Guidelines
        Canadian Journal of CardiologyVol. 35Issue 10
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          The practice of electrical or pharmacological cardioversion (CV) to restore sinus rhythm in patents with symptomatic atrial fibrillation (AF) or atrial flutter has been a part of clinical practice for more than 100 years. For almost as long as CV has been performed, it has been recognized that the act of restoring sinus rhythm is associated with an increased risk of stroke and systemic embolism, and that oral anticoagulant (OAC) therapy can be used to prevent peri-CV thromboembolism. Although it has been widely accepted that OAC therapy is necessary to prevent thromboembolism in patients with chronic AF/atrial flutter who undergo CV, previous clinical practice recommendations have suggested that OAC therapy may be omitted in patients at low risk of stroke.
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