Do you resume flecainide and metoprolol (beta blockers) after cardioversion?

Management of Medications After Cardioversion for Atrial Fibrillation

Yes, flecainide and metoprolol should be resumed after cardioversion as part of a long-term rhythm control strategy to prevent recurrence of atrial fibrillation.

Rationale for Continuing Medications

Flecainide After Cardioversion

• Flecainide is specifically recommended as a useful agent to enhance the success of direct-current cardioversion and prevent recurrent AF (Class IIa recommendation, Level of Evidence: B) 1
• Continuing flecainide after cardioversion is more effective than short-term treatment in maintaining sinus rhythm
• In patients who relapse to AF after successful cardioversion, it is useful to repeat the procedure following prophylactic administration of antiarrhythmic medication like flecainide 1

Metoprolol (Beta-Blocker) After Cardioversion

• Beta-blockers like metoprolol are recommended for rate control and can be considered to enhance cardioversion success and prevent early recurrence 1
• Beta-blockers are particularly important when using flecainide to prevent rapid AV conduction in case atrial flutter occurs 1
• For patients with persistent AF, beta-blockers may be considered to enhance the success of direct-current cardioversion, although their efficacy is less established than antiarrhythmic drugs like flecainide 1

Timing and Administration

1. Resume medications immediately after successful cardioversion

   • Both medications should be continued at their previous effective doses
   • No washout period is necessary between cardioversion and medication resumption

2. Flecainide dosing

   • Typical maintenance dose: 50-200 mg every 12 hours 1
   • Should be avoided in patients with:
     • Structural heart disease
     • Coronary artery disease
     • Significant left ventricular dysfunction
     • Conduction system disease

3. Metoprolol dosing

   • Continue at previous effective dose for rate control
   • Serves dual purpose of rate control and enhancing maintenance of sinus rhythm

Duration of Therapy

• Long-term treatment is superior to short-term treatment for maintaining sinus rhythm after cardioversion 2
• Research shows that short-term (4 weeks) antiarrhythmic drug treatment after cardioversion is less effective than long-term (6 months) treatment 2
• For patients with recurrent symptomatic AF, indefinite continuation of antiarrhythmic therapy may be necessary

Monitoring After Cardioversion

1. ECG monitoring within 2-4 weeks to assess maintenance of sinus rhythm 3
2. Regular follow-up visits to:
   • Monitor heart rate control
   • Assess for development of symptoms
   • Evaluate for adverse effects of medications
   • Reassess stroke risk periodically

Important Considerations and Precautions

• Flecainide safety: Ensure patient does not have contraindications such as structural heart disease, coronary artery disease, or significant conduction system disease
• Proarrhythmic risk: Monitor for QRS widening, QT prolongation, or new arrhythmias
• Anticoagulation: Continue anticoagulation for at least 4 weeks after cardioversion in all patients, and long-term anticoagulation should be based on CHA₂DS₂-VASc score 1

Special Situations

• If AF recurs despite medication, consider:
  1. Increasing dose if tolerated
  2. Switching to alternative antiarrhythmic drug
  3. Repeat cardioversion with continued antiarrhythmic therapy 1
  4. Catheter ablation if recurrences continue despite antiarrhythmic drugs

Conclusion

The combination of flecainide and metoprolol represents an effective strategy for maintaining sinus rhythm after cardioversion, with flecainide preventing AF recurrence and metoprolol providing rate control and enhancing the efficacy of flecainide. This approach is supported by current guidelines and clinical evidence.