What is the treatment for Atrial Fibrillation (AF) with cardiogenic shock?

From the Guidelines

Atrial fibrillation (AF) with shock treatment should be managed according to the 2024 ESC guidelines, which recommend electrical cardioversion in cases of haemodynamic instability, with anticoagulation for at least 3 weeks beforehand if AF duration exceeds 24 hours 1.

Key Considerations

• The decision to perform cardioversion should be based on the patient's individual risk of thromboembolism and the presence of haemodynamic instability.
• Anticoagulation is crucial before and after cardioversion to prevent thromboembolic events, with the choice of anticoagulant depending on the patient's risk factors and renal function.
• The procedure should be performed by experienced healthcare professionals, with adequate sedation and monitoring to ensure patient safety.

Management Approach

• Prior to cardioversion, patients should undergo thorough evaluation, including medical history, assessment of symptoms, and risk factors for thromboembolism and bleeding 1.
• The CHA2DS2-VA score should be used to assess the risk of thromboembolism, with anticoagulation recommended for patients with a score of 2 or higher 1.
• Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists (VKAs) for anticoagulation, unless the patient has a mechanical heart valve or mitral stenosis 1.

Post-Cardioversion Management

• Anticoagulation should be continued for at least 4 weeks post-procedure, regardless of the patient's CHA2DS2-VA score 1.
• Antiarrhythmic medications may be prescribed to maintain sinus rhythm, with the choice of medication depending on the patient's individual risk factors and medical history.
• Regular follow-up is necessary to monitor the patient's condition and adjust treatment as needed to prevent adverse outcomes and improve quality of life.

From the Research

Treatment Options for Atrial Fibrillation (AF) with Shock

• Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion) 2.
• Pharmacological cardioversion using intravenous antiarrhythmic agents is commonly indicated in symptomatic patients with recent-onset atrial fibrillation (AF), except in hemodynamically unstable patients who require emergency direct current electrical cardioversion 3.
• For patients with AF and shock, cardioversion should be performed if the patient is hemodynamically unstable 4.

Pharmacological Cardioversion

• Intravenous antiarrhythmic agents such as flecainide, propafenone, amiodarone, sotalol, dofetilide, ibutilide, and vernakalant are commonly used for pharmacological cardioversion 3.
• The choice of antiarrhythmic agent depends on the patient's clinical status, the duration of AF, and the experience of the treating physician 4.
• Antazoline, an old antihistaminic agent with antiarrhythmic properties, has also been reported to give encouraging results in Poland 3.

Electrical Cardioversion

• Electrical cardioversion is a highly effective treatment for AF, with success rates ranging from 70% to 90% 2.
• The use of anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion has been shown to result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up 2.
• Electrical cardioversion should be performed by a physician with experience in sedation, or anaesthetics support 2.

Management of AF in the Emergency Department

• The management of AF in the emergency department (ED) involves initiation of oral anticoagulant (OAC) therapy, cardioversion, and arranging for outpatient follow-up 5.
• Published treatment protocols for AF in the ED have been shown to reduce unnecessary hospital admissions and improve adherence to guideline-directed OAC therapy 5.
• The goal of treatment is to prevent and control AF, and to reduce the risk of morbidity, disability, and mortality associated with AF 6.