A 62-year-old woman attends clinic following an ED attendance 6 weeks previously with a one-week history of palpitations. She was diagnosed with AF at the time and commenced on aspirin and a beta-blocker. Her echocardiogram showed no significant abnormalities and her ECG in clinic today confirms atrial fibrillation with a ventricular rate of 70 bpm. She continues to get occasional palpitations and would like to be considered for cardioversion.
What do you advise?
Patients should be anticoagulated with a therapeutic INR (>2) for at least 3 weeks prior to cardioversion. Anticoagulation should be continued for at least 4 weeks post-cardioversion as ‘atrial stunning’ may occur. Anticoagulation is required prior to both chemical and electrical cardioverison. If a patient has not had oral anticoagulation for at least 3 weeks, it is reasonable to perform DC cardioversion if a TOE rules out left atrial thrombus. However, LMWH should be commenced prior to a TOE-guided cardioversion and continued post-cardioversion until the target INR is reached with oral anticoagulation.