Therapy

DC cardioversion

Consider using transoesophageal echocardiography to determine when to perform the cardioversion ^a

• No thrombus detected - DC cardioversion, and warfarin for 4 weeks. 
• Thrombus detected - warfarin for 3 weeks, then repeated echocardiogram. 
  • If no thrombus then, DC cardioversion and warfarin for 4 weeks. 
  • If thrombus, no DC cardioversion and warfarin for 4 weeks.

Why?

• Using transoesophageal echocardiography to determine when cardioversion should occur leads to fewer bleeds on warfarin but has no clear effect on embolic events or the duration of any sinus rhythm achieved. ^d
• Using it to predict which patients require anticoagulation ^b has no clear effect on subsequent embolic events. ^d

Ibutilide is effective at cardioversion, but cause ventricular tachycardia

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
AF for > 2 days or atrial flutter with a history of AF a	DC cardioversion guided by transoesophageal echocardiography	standard DC cardioversion	haemorrhage at 8 weeks	5.5%	47% (7% to 70%)	39 (21 to 320)