From the FDA Drug Label
Patients in registration trials were hemodynamically stable. Patients with specific cardiovascular conditions such as symptomatic heart failure, recent acute myocardial infarction, and angina were excluded
The FDA drug label does not answer the question.
From the Research
The likelihood of converting a patient out of atrial fibrillation (AF) with cardiogenic shock after unsuccessful cardioversion via intravenous medications is generally low, and the focus should shift to hemodynamic stabilization rather than rhythm control. In this critical situation, immediate electrical cardioversion is recommended as the first-line approach rather than continuing with pharmacological attempts. For patients with cardiogenic shock, the underlying hemodynamic compromise takes precedence, and addressing the shock with vasopressors (such as norepinephrine 0.1-0.5 mcg/kg/min or epinephrine 0.01-0.5 mcg/kg/min) and inotropes (such as dobutamine 2-20 mcg/kg/min) is essential, as supported by the principles outlined in various studies 1, 2, 3, 4, 5.
Key Considerations
- The use of antiarrhythmic drugs such as amiodarone may be considered if electrical cardioversion has already failed, given its relatively safer profile in patients with structural heart disease and left ventricular systolic dysfunction 5.
- Mechanical circulatory support like intra-aortic balloon pump or VA-ECMO may be necessary in severe cases to stabilize the patient's hemodynamics.
- The poor response to cardioversion attempts in this setting is often due to the underlying cardiac dysfunction, metabolic derangements, and catecholamine surge associated with shock, which create an environment highly conducive to arrhythmia persistence.
Recommendations
- Hemodynamic stabilization should be the primary focus in managing patients with atrial fibrillation and cardiogenic shock, rather than attempting rhythm control through cardioversion.
- If pharmacological cardioversion is considered, amiodarone could be an option due to its safety profile in patients with structural heart disease, as noted in studies such as 5.
- Electrical cardioversion should be attempted as the first-line approach for rhythm control in these critical situations, given its immediacy and potential for rapid restoration of sinus rhythm.