Cardioversion may be achieved with drugs that stabilise the atrial myocardium, for example:
Digoxin has no role in chemical cardioversion. The same precautions that are indicated in electrical cardioversion also apply to chemical cardioversion.
Remember that the antiarrhythmic drugs which are used in chemical cardioversion may themselves precipitate arrhythmias.
There is evidence that amiodarone is more effective than sotalol in maintaining sinus rhythm in patients who had had atrial fibrillation (2).
NICE state in updated guidance (3)
- for people having cardioversion for atrial fibrillation that has persisted for longer than 48 hours, offer electrical (rather than pharmacological) cardioversion
- consider amiodarone therapy starting 4 weeks before and continuing for up to 12 months after electrical cardioversion to maintain sinus rhythm, and discuss the benefits and risks of amiodarone with the person.
- for people with atrial fibrillation of greater than 48 hours' duration, in whom elective cardioversion is indicated
- both transoesophageal echocardiography (TOE)-guided cardioversion and conventional cardioversion should be considered equally effective
- a TOE-guided cardioversion strategy should be considered:
- where experienced staff and appropriate facilities are available and
- where a minimal period of precardioversion anticoagulation is indicated due to the person's choice or bleeding risks
Drug treatment for long-term rhythm control
If drug treatment for long-term rhythm control is needed, consider a standard beta-blocker (that is, a beta-blocker other than sotalol) as first-line treatment unless there are contraindications
If beta-blockers are contraindicated or unsuccessful, assess the suitability of alternative drugs for rhythm control, taking comorbidities into account
Dronedarone is recommended as an option for the maintenance of sinus rhythm after successful cardioversion in people with paroxysmal or persistent atrial fibrillation:
- whose atrial fibrillation is not controlled by first-line therapy (usually including beta-blockers), that is, as a second-line treatment option and after alternative options have been considered and
- who have at least 1 of the following cardiovascular risk factors:
- hypertension requiring drugs of at least 2 different classes
- diabetes mellitus
- previous transient ischaemic attack, stroke or systemic embolism
- left atrial diameter of 50 mm or greater
- or age 70 years or older and
- who do not have left ventricular systolic dysfunction and
- who do not have a history of, or current, heart failure
Consider amiodarone for people with left ventricular impairment or heart failure
Do not offer class 1c antiarrhythmic drugs such as flecainide or propafenone to people with known ischaemic or structural heart disease.
The summary of product characteristics should be consulted before prescribing drugs mentioned in this database.
* persistent AF does not self-terminate, or lasts longer than 7 days (without cardioversion)
**coronary artery disease or left ventricular dysfunction
Last reviewed 01/2018