#procedures see: [Electrical cardioversion - Dunn](x-devonthink-item://292A36BC-3ABB-4552-A39B-F8FC03E82D7C) , [Atrial fibrillation mgmt Dunn](x-devonthink-item://A1A18198-7B1E-4E86-A927-375D9A7134B7), [Robert Hedges - Cardioversion](x-devonthink-item://31ACDC98-D2CC-48C5-BE69-E9B37E53FA8C?page=320&istart=812&ilength=12&search=CARDIOVERSION) see also: [[Ventricular Tachycardia]], [[Atrial fibrillation]], [[APLS#paeds VT]] [2023 AHA guideline-8.2.1. Prevention of Thromboembolism in the Setting of Cardioversion](bookends://sonnysoftware.com/pdf/DL/291677/1723309448/68) [2018 australia AF guidelines 6.3.4.6.](bookends://sonnysoftware.com/pdf/DL/201032/1723356880/37) [AF cardioversion anticoagulation slides](x-devonthink-item://0E68FBE5-B2D8-41FF-8FC3-51906AFE861E) #incomplete (this page mostly just discusses anticoagulation) > [!Key Points] > - LMWH for all cardioversion 1mg/kg (not formal guideline) > - Follow up anti-coagulation 3 weeks unless <12 h and CHADSVasc 0 > - ==100J biphasic== (repeat at same if fails) > - 200J if if obese or failure > > > You CAN cardiovert or defibrillate a patient with PPM or ICD. To avoid damage to the pacemaker device, shocking pads should be placed in the anterior-posterior position and at least 10 cm from the unit. The pacemaker (or ICD) should be checked before and afterwards **Defibrillation** - delivery of electrical energy in non-synchronised mode - used in VF and pulseless (arrested) VT **Cardioversion** - delivery of energy in *synchronised* mode - tachyarrhythmias in "unstable" patients (eg hypotension, pulm oedema, ALOC, ischaemic chest pain) - tachyarrhythmias in stable pts where medical treatment has failed - tachyarrhythmias where electrical reversion may be considered best first line treatment (eg AF <48 hours, or [[Syncope ECG patterns#WPW|WPW AF]] # contraindications - digoxin overdose (can precipitate ventricular arrhythmias) # anticoagulation - **Enoxaparin 1mg/kg** - ==If duration > 12 hours and stable, likely discuss with cardiology re: TOE DCR== → may be rhythm control and 3 weeks of anticoagulation - **apixaban 5mg bd** - “Although data from RCTs are lacking, it is reasonable for patients with lone AF (without thromboembolic risk factors) and a known arrhythmia onset time within 48 hours prior, to undergo cardioversion without administering 1 month of periprocedural anticoagulation. However, determining the arrhythmia onset time may be difficult and imprecise in all but the youngest and most symptomatic paroxysmal AF patients. Patients with established, ambient AF *may develop a sudden onset of symptoms when adrenergic factors lead to a precipitant onset of rapid ventricular response*. ==Where there is any doubt, the periprocedural anticoagulation recommendations outlined above should be followed==.” — [2018 Australia national heart](bookends://sonnysoftware.com/annotation/DL/201032/1723356880/37/-295/-281) - “Anticoagulation for Cardioversion. Recommendation: Anticoagulation is recommended at the time of electrical or pharmacological cardioversion, and for at least 4 weeks post-procedurally.” - “The safety of cardioversion without further assessment or previous anticoagulation in patients with AF duration of <48 hours has been challenged. In addition to concerns for underestimation of actual duration of episode and burden due to potential for asymptomatic occurrence of AF, emerging data demonstrate that thromboembolic risks in patients with <48 hours of AF were not homogenously low. ==Time to cardioversion >12 hours has been reported as an independent predictor for thromboembolic complications.== A single-center observational study of patients undergoing cardioversion for AF of <48 hours duration did not observe thromboembolic events in patients with CHA2DS2-VASc score of 0 or 1 or patients with postoperative AF but noted differential thromboembolic rates in CHA2DS2-VASc score ≥2.42 Larger studies similarly demonstrated that among patients with <48 hours of AF, postcardioversion thromboembolic risks increased with increasing CHA2DS2-VASc score, especially if ≥ 2.” [AHA 2023](bookends://sonnysoftware.com/annotation/DL/291677/1723309448/70/-314/-255) - “The combination of CHA2DS2-VASc of 0 to 1 in conjunction with duration of <12 hours of AF may identify a population at particularly low risk for pericardioversion thromboembolism” - AHA 2023 - “***No randomized trial has evaluated anticoagulation compared with no anticoagulation in AF patients undergoing cardioversion with a definite duration of AF <48 hours***. Observational data suggest that the risk of stroke/thromboembolism is very low ==(0  to 0.2 percent)== in patients with a definite AF duration of <12 hours and a very low stroke risk (CHA2DS2-VASc 0 in men, 1 in women), in whom the benefit of four-week anticoagulation after cardioversion is undefined. The 2020 European Society of Cardiology guidelines for the diagnosis and management of AF suggest that prescription of anticoagulants can be optional, based on an individualized approach.” - Age greater than 60 years, female sex, heart failure, and diabetes were the strongest predictors of embolization, with nearly 10 percent of those with both heart failure and diabetes experiencing a stroke. The risk of stroke in those without heart failure and age less than 60 years was 0.2 percent. An observational study of 16,274 patients undergoing electrical cardioversion with and without oral anticoagulant therapy also demonstrated that the absence of postcardioversion anticoagulation was associated with a high risk of thromboembolism, regardless of CHA2DS2-VASc scores. ![[Pasted image 20241005202654.png|ACC AF guideline anticoagulation 2023]] # Related Questions ## cardioversion - [ ] 2Q: [VT](x-devonthink-item://2CB6E202-E7C1-46E8-B49F-435AB6C937F0?page=16) -- [Answer](x-devonthink-item://78503782-404C-41A2-A3AE-B1A26F578DF5?page=19) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=7) - [ ] 3Q: [Atrial Fibrillation](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=44) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=20) - [ ] 4Q: [Hypotensive SVT Patient](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=29) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=19)