When should you consider cardioversion for atrial fibrillation?


  • afib with rapid rate that causes hemodynamic instability or severe heart failure, MI


  • symptomatic, persistent afib (causing CHF exacerbations, for example)
  • symptomatic, new afib due to an underlying cause (e.g., hyperthyroidism, post-op, PE) after that cause is treated
  • before cardioverting, ask about anticoagulation–if afib has been present for >48 hrs, either TEE to rule out atrial thrombus or 3-4 weeks of anticoagulation is recommended. That being said, even when cardioversion is done in the ER with no anticoagulation the risk of clot at 30 days is 0% – 0.7%


  • patients with infrequent, but symptomatic episodes who don’t have a pattern of spontaneously converting back to sinus rhythm
  • as part of a plan for long-term rhythm control, cardioversion is performed before starting patients on oral antiarrhythmics

Cardiology is more likely to say no to patients who are…

  • stable, completely asymptomatic patients 🙂
  • >80 years age, multiple medical comorbidities
  • patients who have not been anticoagulated or are not candidates for anticoagulation
  • left atrial dilation or other structural features that make afib more likely to recur

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