The Living Guidelines: Prevention of thromboembolism in patients with atrial fibrillation undergoing cardioversion: Suggest Revisions to the CLASS I Guidelines

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Class I Guidelines

 * 1) For patients with AF of 48-h duration or longer, or when the duration of AF is unknown, anticoagulation (INR 2.0 to 3.0) is recommended for at least 3 week prior to and 4 wk after cardioversion, regardless of the method (electrical or pharmacological) used to restore sinus rhythm. (Level of Evidence: B)
 * 2) For patients with AF of more than 48-h duration requiring immediate cardioversion because of hemodynamic instability, heparin should be administered concurrently (unless contraindicated) by an initial intravenous bolus injection followed by a continuous infusion in a dose adjusted to prolong the activated partial thromboplastin time to 1.5 to 2 times the reference control value. Thereafter, oral anticoagulation (INR 2.0 to 3.0) should be provided for at least 4 wk, as for patients undergoing elective cardioversion. Limited data support subcutaneous administration of low molecular weight heparin in this indication. (Level of Evidence: C)
 * 3) For patients with AF of less than 48-h duration associated with hemodynamic instability (angina pectoris, acute MI, cardiogenic shock, or pulmonary edema), cardioversion should be performed immediately without delay for prior initiation of anticoagulation. (Level of Evidence: C)