Cardioversion of Atrial Fibrillation:

Electrical vs Pharmacological

Andrew C Rankin

Conflicts of interest: Speaker and consultancy fees (Sanofi Aventis)

 Algorithm for treatment of AF!

First episode

Paroxysmal Persistent Permanent

Peters N, et al. Lancet 2002

 Different types of AF

Paroxysmal
(usually <48 h)

ESC AF Guidelines 2010

“Natural” time course of AF

ESC AF Guidelines 2010

CV, Anticoagulation & TOE

ESC AF Guidelines 2010

 Goals of AF management

Improvements in:
• Symptoms
• Outcomes
 Cardiac output following CV

% Change in CO

Time after restoration of sinus rhythm

Upshaw, Arch Intern Med 1997;157:1070

Functional capacity following CV

Oxygen consumption Heart rate

Gosselink et al, Br Heart J 1994;72:161

 The AFFIRM study

30
Cumulative mortality (% patients)

25

20

15
Rhythm control
(Electrical CV 38%)

10
Rate control

(p=0.08; N=4060 )
0
0 1 2 3 4 5
Years

The AFFIRM Investigators. N Engl J Med 2002

Choice of Rhythm or Rate control

ESC AF Guidelines 2010

CV of recent onset AF

Rate control

ESC AF Guidelines 2010

 Pharmocological Cardioversion

* “Pill in the pocket”

ESC AF Guidelines 2010

Intravenous drugs for AF
150 patients, AF<48h
Flecainide
90%
Propafenone
72%
64%
Amiodarone

Martinez-Marcos et al, 2000

The AVRO trial

Camm et al, 2011; JACC

 Electrical Cardioversion of AF

I 150J
10J

II

III
 Electrical Cardioversion of AF

• Anticoagulation
• GA or sedation
• Biphasic shock
• AP or AL electrode position
• Electrolytes
• Devices
 Electrical vs Pharmacological CV

ECV PCV
Efficacy +++ ++
Pro-arrhythmia + ++
Logistics +++ +
GA / sedation + -
Stroke risk + +
 RHYTHM-AF – European Registry of CV

1795 ECV 1609 success (90%)

2723 CV
928 PCV 636 success (69%)

115 to ECV (12.4%)

3943
ECV = Electrical CV
PCV = Pharmacological CV

1220 No CV

Crijns HJGM; ESC Congress 2011

RHYTHM-AF – European Registry of CV

No CV (n=1220)

Spontaneous SR - 32.6%

Uncertain duration - 7.7%

CV post discharge - 30%

Crijns HJGM; ESC Congress 2011

 RHYTHM-AF – European Registry of CV

No CV CV ECV PCV

Europe 31% 69% 66% 34%

UK 42% 58% 85% 15%

Crijns HJGM; ESC Congress 2011

 Recurrence of AF after CV
Follow-up of 124 patients with normal LV

Recurrence free %
100

80

60

40

20

0
0 1 2 3 4
Follow-up (years)

Suttorp et al, 1993

Amiodarone vs Sotalol for AF

Singh et al (SAFE-T) NEJM 2005;352:1861

 ECV vs PCV: Indications

Electrical CV Pharmacological CV

AF <48 h duration (+) +++

AF < 7 d + +

AF > 7 d +++ (+)

AF pretreated
+++ (+/-)
with AAD / amio

Aliot E; ESC Congress 2011

Early CV and recurrence after RFA

Winkle et al, 2011; AJC

Early CV and recurrence after RFA

Winkle et al, 2011; AJC

 N3-PUFAs post-CV for AF

n-3 PUFAs

Placebo

• Persistent AF
• Previous CV
• Amio + ACEI/ARB

Nodari et al, 2011; Circ

Acupuncture and AF recurrence

Lomuscio et al, 2011; JCE

Acupuncture and AF recurrence

• 10 sessions
• 15-20 min
• weekly

Lomuscio et al, 2011; JCE

 Cardioversion of AF

Conclusions
• CV should be considered for
selected patients with AF
• Either electrical or pharmacological
(or both)
• Early CV is better