MedifocusHealth

The traditional approach for cardioversion is to anticoagulate the patient with Coumadin and have the patient at therapeutic levels of Coumadin (INR levels between 2 and 3) for at least three weeks. Following this three week interval, cardioversion is attempted either with medications or by DC shock. In some cases medications are used first and DC shock is used only if the medications fail. One oral dose of propafenone (600 mg) has been effective in cardioverting patients. Flecanide (300 mg) given orally is also effective. The newer drugs include dofetilide (0.5 mg) given twice daily orally (a smaller dose is recommended for patients with renal disease). In the hospital, ibutilide may be used intravenously as may be amiodarone. In some medical centers, DC shock is used directly. After cardioversion, anticoagulation therapy is continued to prevent clot formation.

A more recent approach, especially in patients with more recent onset atrial fibrillation, is to start the patient on heparin and then perform transesophageal echocardiography to look for blood clots especially in the left atrial appendage. Transesophageal echocardiography, also known as TEE or heart scan with endoscopy, is a procedure used to evaluate the heart's function and structure through the use of sound waves.

If no clot is visualized by transesophageal echocardiography, cardioversion can then be done either with medications or with DC shock. The advantage of this approach is that it decreases the amount of time that the patient is in atrial fibrillation thus preventing dilatation of the left atrium which occurs as atrial fibrillation persists. This dilatation of the left atrium decreases the chance that the atrial fibrillation will be reverted back to sinus rhythm. After the patient is reverted back to sinus rhythm, it is important to keep the patient on anticoagulation with Coumadin for at least 3-4 months. This is to prevent blood clots which can form in the atria which are stunned from the cardioversion and also to prevent blood clots from intermittent episodes of atrial fibrillation which may occur for several months after cardioversion.