Pharmacological cardioversion of atrial fibrillation: practical considerations

The choice between rhythm and rate control strategy represents one of the most intriguing dilemmas in the management of atrial fibrillation (AF). Although the advantage of rhythm over rate control in terms of outcome has not been unequivocally proven, the initial management of patients with symptomatic episodes of AF frequently involves early cardioversion. As electrical cardioversion (EC) is challenging in terms of fasting status and involvement of an anesthesiologic team, pharmacological cardioversion (PC) is usually selected as the first step toward rhythm conversion. Qualification criteria for PC or EC are similar and should comprise assessment of hemodynamic status, estimation of arrhythmic episode duration, evaluation of anticoagulation regimen, exclusion of other supraventricular arrhythmias, and assessment of the chance of rhythm conversion and persistence of sinus rhythm. Finally, the choice of adequate antiarrhythmic drug (AAD) depends on the presence of structural heart disease (SHD) and local experience. In patients without any SHD, complications occur rarely, hence traditional (propafenone, flecainide) or nonclassical Vaughan-Williams class I (antazoline) or class III (vernakalant, ibutilide, or dofetilide) drugs are preferred. The presence of SHD consistent with any left ventricular hypertrophy, heart failure, myocardial ischemia, or valvular heart disease limits the choice of AAD to amiodarone. Given the risk of ventricular proarrhythmia of AAD, safety should always prevail over the enticing possibility of rhythm conversion. The present review aims to provide a comprehensible summary of proper qualification for PC, selection of suitable AAD, and state‑of‑the‑art periprocedural management of patients with recent‑onset AF.