Mount Carmel Health Partners Clinical Guidelines Atrial Fibrillation | Page 9

TABLE F: Pre and Post-Cardioversion Anticoagulation
Pre-cardioversion—3 options
If 4 weeks therapeutic anticoagulation with apixaban, rivaroxaban, dabigatran, edoxaban or warfarin (INR
range 2-3 or if patient has mechanical value, INR 2.5 to 3.5) then elective DC cardioversion is acceptable.
If AF <48 hours AND NO history of mitral stenosis/prosthetic values, TIA, stroke, or thromboembolism
(CHA₂DS₂ VASc >5), then DC cardioversion without TEE is acceptable. If patient is not fully anticoagulated,
give enoxaparin (30 mg IV and 1 mg/kg SCQ) or heparin or therapeutic NOAC dose before cardioversion.
IF AF ≥ 48 hours (or duration unknown) OR there are any of the thrombosis risk factors above, then TEE
guided cardioversion is warranted. If patient is not fully anticoagulated, give enoxaparin (30 mg IV and
1 mg/kg SCQ) or heparin drip per protocol before cardioversion or novel oral anticoagulant (NOAC).
Post-cardioversion
30-days of therapeutic anticoagulation for all patients regardless of CHA 2 DS 2 VASC score; anticoagulation is
important due to the risk of AF recurrence during this time window. Warfarin, apixaban, rivaroxaban,
edoxaban, or dabigatran may be used; if warfarin is used, bridge with enoxaparin until therapeutic INR has
been achieved for 2 days.
Evaluate need for chronic anticoagulation based on CHA 2 DS 2 VASC score.
TABLE G: Rhythm Control
Why it’s important: The longer the patient is in AF, the more likely the condition is to become
permanent. Control should be achieved ASAP.
DC cardioversion: Should be pursued unless risks outweigh benefits or there is a low chance
of success.
Antiarrhythmic medications:
Post-cardioversion: consider medication unless it is the first episode and
there is no structural heart disease. Chronic: referral to cardiologist.
TABLE H: Chronic Rate Control
When to consider:
Treatment goal:
Strategy:
Patients with the factors listed in Table D and patients for whom
rhythm control has failed
60 to 100 bpm
Use diltiazem or verapamil and/or beta blocker, unless EF <35%;
options include digoxin and amiodarone
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