Thursday, March 23, 2023

How To Stay In Sinus Rhythm After Cardioversion

What To Think About

Atrial Fibrillation Treatment ð?¥ Cardioversion Procedure

Cardioversion can also be done with medicines. These medicines are called rhythm control medicines, or antiarrhythmics. These medicines can also help keep your heart in a normal rhythm after it has been reset. You may get pills, or the medicine may be put into your arm through a tube called an IV. If an IV is used, it will be done in the hospital. You may start pills in the hospital and continue taking them at home, or you may start the pills at home.

What Is The Best Strategy To Follow In Very Old Patients With Atrial Fibrillation: Rate Or Rhythm Control

Assoc. Prof Lidija Poposka

Management of atrial fibrillation in the rapidly growing population of older patients involves a comprehensive strategy that includes consideration of their comorbidities, functional and social status. Activity level and medication tolerance are different in this category of patients and expectations are focused on quality of life and symptom relief. Invasive methods, such as catheter ablation, are the new frontier of treatment for maintaining sinus rhythm in this population with complication rate comparable to younger patients.

Success Rate Of Cardioversion

Electrical Cardioversion is considered a standard, routine, low risk treatment option, particularly for recent onset A-Fib patients. If your A-Fib has just started, it may be a momentary aberration and an Electrical Cardioversion may correct it.

Cardioversion has a very high initial success rate, returning up to 95% of A-Fib patients to NSR.

While the conversion rate is high, recurrence of A-Fib is high too. Cardioversion doesnt prevent future episodes of A-Fib. As few as 23% of patients remain in normal sinus rhythm for more than one year post-procedure. For most, their A-Fib returns within the first five days.4

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Prediction Of Maintaining Sinus Rhythm Post

Previous studies have shown that type of underlying disease, AF duration and the patients functional class are predictors of maintaining sinus rhythm after cardioversion. Radiographic determined heart size and increased of the mitral inflow Doppler A-wave amplitude 4 to 24 hours post cardioversion also predict AF recurrence. Some studies have found that increased left atrial diameter is a predictor of AF relapse, but data is conflicting. Our study found a trend for atrial diameter to be greater in patients who ultimately relapsed back into AF, but this failed to reach statistical significance. Overall these clinical and echocardiographic parameters have low predictive value and a more refined tool is needed.

Catheter Ablation Of Af In The Elderly

ECG immediately after cardioversion, demonstrating sinus ...

For years, patients over 75 years were excluded from catheter ablation trials for safety reasons. Improvements in ablation techniques have given elderly patients a chance for rhythm control treatment with a rate of complications comparable to a younger population.

In a large worldwide survey, major periprocedural and post-procedural complications of catheter ablation, including death, cardiac tamponade, strokes, and transient ischaemic attacks, were reported in 4.5% of cases, regardless of age at the time of the procedure .

Data from small retrospective studies show that the multiple procedure success rate for paroxysmal AF in patients over 75 years is comparable with younger patient cohorts however, it was less favourable for persistent and long-standing persistent AF . The safety profile was comparable with younger patient cohorts, with a major complication rate of 5.8% . The study by Nademanee et al showed that elderly patients with AF benefit from AF ablation, which is safe and effective in maintaining sinus rhythm . The complication rate during the first 24 hrs was 7.3%, out of which only 3.4% were major complications . Only 6.5% of patients were re-hospitalised in the first month, 2.7% due to groin complications – bleeding, pseudoaneurysm – and 2.7% due to atrial tachycardia. Maintaining sinus rhythm in this population by catheter ablation was feasible in approximately 80% of patients, although a significant number of patients required more than one procedure .

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What To Expect After Treatment

After cardioversion, you will be monitored to make sure that you have a stable heart rhythm.

You might take a medicine that prevents blood clots before and after you have cardioversion. This medicine lowers your risk of a stroke.

Additional medicines to help prevent the return of heart rhythm problems also may be given before and after the procedure. Your risk of having atrial fibrillation again is greater if antiarrhythmics are not used after cardioversion.

Signal Recording And Analysis

A monophasic defibrillator was used for cardioversion and simultaneous on-line ECG recording. ECG signals of atrial fibrillation in length of 25s before cardioversion were analyzed using MatLab R12 .

Measurement of RR intervals was made from the original time-domain ECG signal by calculating the difference between different consecutive R spikes using the same computer programme.

Mean and standard deviation of consecutive RR intervals were calculated.

Approximate entropy , which is used in nonlinear analysis of RR, was calculated from the same RR intervals. ApEn measures the logarithmic likelihood that runs of patterns that are close to each other will remain close in the subsequent incremental comparison. A series containing many repetitive patterns has a relatively small ApEn conversely, more random data produce higher values. Details of this method have been previously described .

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Monitors Used During The Procedure

Cardioverter: Attached to restoreone sticky patch placed on the normalcenter of your back and one on your chest. This lets your healthcare team control your heart rhythmrate and deliver energy to your heart muscle.

ECG/EKG: Keeps track of your heartâs electrical activity. Several sticky patches are attached to your chest, and wires carry the information to a machine that creates a graph.

Blood pressure monitor: A cuff on your arm will inflate and deflate to keep track of the pressure inside your blood vessels.

Oximeter: A small clip on your finger measures the amount of oxygen in your blood.

Reverting Back To Afib After Cardioversion

Cardioversion of Atrial Flutter

A cardioversion procedure is a treatment for afib that does not involve an operation. Its goal is to bring your heart rhythm back to normal. There are two types of cardioversion:

  • Chemical cardioversion involves taking medication to convert your rhythm.
  • Electrical cardioversion sends an electrical shock to your heart to restore its normal rhythm.

Electrical for afib usually works right away, but afib often comes back. This could happen in a few days or even just a few minutes. If that happens, your heartbeat may become very fast and irregular once again. You might feel like youre running a marathon, even if youre sitting down. This happens because irregular electrical signals are moving through your heart.

Some people dont notice warning signs of this. Others experience some common symptoms like:

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Lower Your Pulse Or Reset Your Heart Rhythm

Most people who have only have treatment to slow down their heartbeat. The aim of this treatment to control the heart rate is to reduce the hearts workload and relieve bothersome symptoms. Beta blockers are typically used to lower the resting heart rate to less than 110 beats per minute at first. If that isnt enough to relieve the symptoms, doctors can try to lower the resting heart rate further, either by using a higher dose of the same medication or using additional medications.

Another option is to try to restore the normal sinus rhythm, either with medication or by delivering a small electric shock. The medical term for this is pharmacological or electrical cardioversion. After cardioversion, people typically take medication to stabilize their heart rate and ultimately prevent from recurring.

Cleveland Clinic Heart Vascular & Thoracic Institute Cardiologists And Surgeons

Choosing a doctor to treat your abnormal heart rhythm depends on where you are in your diagnosis and treatment. The following Heart, Vascular & Thoracic Institute Sections and Departments treat patients with Arrhythmias:

Section of Electrophysiology and Pacing: cardiology evaluation for medical management or electrophysiology procedures or devices – Call Cardiology Appointments at toll-free 800.223.2273, extension 4-6697 or request an appointment online.

Department of Thoracic and Cardiovascular Surgery: surgery evaluation for surgical treatment for atrial fibrillation, epicardial lead placement, and in some cases if necessary, lead and device implantation and removal. For more information, please contact us.

You may also use our MyConsult second opinion consultation using the Internet.

The Heart, Vascular & Thoracic Institute also has specialized centers to treat certain populations of patients:

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Predicting The Success Of Cardioversion For Afib

Cardioversion restores a normal heartbeat rhythm 90% of the time. However, more than half of these people develop afib again after one year.

When this happens, people sometimes have another electrical cardioversion. If afib returns again, chances are even lower for a third procedure to work. Less than 14% of people who have three procedures are able to maintain a normal heart rhythm.

There are many reasons why electrical cardioversion is more effective for some people than others. For instance, it seems to work better on people who also take medication to control their heart rhythm. It does not seem to work as well on people who have been in constant afib for more than a year. People with an enlarged left atrium may not respond as well to this treatment. Also, cardioversion is more likely to fail in people with untreated , a common sleep disorder.

Choosing cardioversion is an individual decision, but your doctor can help you decide. Talk with your doctor about this procedure if:

  • You have troubling afib symptoms.
  • You have not had afib for long.
  • You had the procedure in the past and your heart rhythm remained normal for a long time afterwards.

You may need to consider other afib treatment options if:

  • You have another affecting your heart rhythm.
  • You had the procedure in the past, and your afib symptoms quickly returned.
  • Youve had afib for a long time.

What Are The Symptoms Of Atrial Fibrillation

Sinus rhythms with LBBB after electrical cardioversion ...

You may have atrial fibrillation without having any symptoms. If you have symptoms, they may include:

  • Heart palpitations – Sudden pounding, fluttering or racing sensation in the chest
  • Lack of energy or feeling over-tired
  • Dizziness – Feeling light-headed or faint
  • Chest discomfort – Pain, pressure or discomfort in the chest
  • Shortness of breath – Having difficulty breathing during normal activities and even at rest

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How Is Atrial Fibrillation Treated

The goals of treatment for atrial fibrillation include regaining a normal heart rhythm , controlling the heart rate, preventing blood clots and reducing the risk of stroke.

Many options are available to treat atrial fibrillation, including lifestyle changes, medications, catheter-based procedures and surgery. The type of treatment that is recommended for you is based on your heart rhythm and symptoms.

Maintaining Sinus Rhythm After Cardioversion Of Atrial Fibrillation

Jean-François Bergmann, MDCardiology Review® Online

We performed a meta-analysis of the effect of long-term treatment with antiarrhythmic drugs for the prevention of recurrent atrial fibrillation after conversion to sinus rhythm. We found that several class IA, IC, and III drugs are effective in maintaining sinus rhythm, but virtually all of them increase adverse effects, including proarrhythmia. In addition, class IA drugs are associated with increased mortality. The final risk-benefit ratio of antiarrhythmic drugs on clinically relevant outcomes is still unclear.

The most frequent sustained arrhythmia is atrial fibrillation, which carries significant morbidity and mortality. A large number of patients recover from atrial fibrillation, either spontaneously or as a result of electrical or pharmacologic cardioversion. But after 1 year, just 20% to 30% of patients will maintain sinus rhythm if no maintenance treatment is provided.1 Many antiarrhythmic drugs have been used and tested for the prevention of atrial fibrillation and maintenance of sinus rhythm. To assess the efficacy of these drugs, as well as to ascertain their effect on proarrhythmia, adverse events, stroke, and mortality, we performed an analysis of randomized controlled trials that evaluated their long-term effects.

Patients and methods


shows the results regarding the various outcomes.


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Prediction Of Successful Restoration Of Sinus Rhythm

Sinus rhythm was restored in 32 of 37 patients. Patients who failed cardioversion tended to have larger left atria and, paradoxically, a longer atrial fibrillatory cycle length. Neither parameter however, nor the combination of the two, proved an important predictor of outcome. Successful cardioversion is dependent upon cardioversion technique and transthoracic impedance, which is influenced by body size, obesity and the presence of pulmonary disease. Some data suggest left atrial enlargement decreases the probability of cardioversion while others do not. Thus although there may be a contribution of electrical and structural remodeling to cardioversion rates, the major determinants are likely to be procedural.

Need A Blood Thinner If In Normal Sinus Rhythm

Cardioversion of Atrial Fibrillation

I was maintaining normal rhythm, so during my October 25, 2016 appointment, I asked Dr. Swarup about getting off the blood thinner Eliquis. .

..he ordered a TEE to check the strength, shape, etc. of my left atrial appendage.

So he ordered a Transesophageal Echocardiogram to check the strength, shape, etc. of my left atrial appendage . From that we could also determine if Eliquis or the Watchman occlusion device would otherwise be feasible.

My LAA pumping velocity was good. Dr. Swarup has taken me off Eliquis, so things have turned out exceptionally well for me.

I had been taking 1 gram of krill oil with the Eliquis. Now that I am off Eliquis, I have decided to double it for now just in casestrictly a personal choice.

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Choosing A Treatment Strategy

The decision regarding whether or not to have treatment to restore your heart rhythm is ultimately a personal decision. It will depend on how you feel about the pros and cons of the treatment. Many medical societies only recommend cardioversion if other treatments arent effective enough.

It is best to talk with your doctor about which treatment strategy is suitable for you. Regardless of whether you decide to have treatment to control your heart rate or treatment to restore your heart rhythm, the decision wont necessarily be final: Your situation may change over time, leading to a change in treatment strategy.

What Is Cardioversion

Cardioversion is a procedure that can be used to correct many types of fast or irregular heart rhythms. The most common of these are atrial fibrillation and atrial flutter. Cardioversion is also used to correct ventricular tachycardia, which is a very fast, life-threatening heart rhythm that starts in the lower chambers of the heart .

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What To Expect

Typically your physician will ask you to be fasting starting the midnight before the procedural day. You may take your medications with a sip of water that morning, but consult your physicians office for specific instructions. You will be brought to a special procedural room where you will be connected to heart and BP monitoring machines. There will be nurses and possibly even anesthesiologists present to monitor you and your respirations during the procedure. Two adhesive pads will be placed on your chest, typically one in the front and one on your back to perform the procedure. After placing you to sleep, a small electrical shock, synchronized to your hearts contractions, will be delivered to the two pads on your chest, capturing the hearts electrical signal and reverting you back to normal sinus rhythm. This shock attempts to electrically capture all of the heart cells, thus interrupting and terminating the abnormal rhythm disturbance.

Figure 4. Illustration of an electrical cardioversion procedure.

Figure 5. Delivery of electrical cardioversion shock with conversion of atrial fibrillation on the left side of the tracing, to normal sinus rhythm on the right.

Typically you will be able to go home the same day of the procedure after a short recovery phase to allow the sedating medications to wash out. Because you have been given sedation, you will need someone to bring you to the hospital and to drive you home.

Why It Is Done

ECG immediately after cardioversion, demonstrating sinus ...

Cardioversion is used:

  • As a non-emergency procedure to stop atrial fibrillation that has not stopped on its own. For people who have just started having episodes of atrial fibrillation, treatment typically includes cardioversion.
  • As an emergency procedure if atrial fibrillation is causing your heart to pump dangerously fast or causing your blood pressure to drop dramatically.

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Ablate And Pace Strategy

There are a few small randomised clinical trials comparing pharmacological rate control and permanent pacing with complete AV node catheter ablation in patients with HF. These trials showed a benefit of an ablate and pace strategy in terms of symptom relief, HF hospitalisations and mortality . AV node ablation solves the problem of rapid ventricular response in AF, which aggravates symptoms and HF.

Catheter ablation of the AV node and permanent pacing should be considered if pharmacological rate control fails . The optimal choice of pacemaker type or pacing mode is still unclear.

Right ventricular or biventricular pacing is the next question which should be answered in the future. There are limited data suggesting an advantage of biventricular pacing versus right ventricular pacing in HF patients.

What Are The Risks Of Cardioversion

If you have atrial fibrillation, blood clots can form in your hearts left atrium. Cardioversion may knock loose a blood clot in your left atrium. If the clot travels to your brain, it can cause a stroke. To avoid this, your doctor may give you medicine to make your blood less likely to form blood clots. If your doctor gives you the medicine, youll need to take it for 2 to 3 weeks before the procedure. Transesophageal echocardiography is often used to check for the presence of blood clots before this procedure.

  • If you have an electrical cardioversion, the skin on your chest or back where the paddles are applied may become irritated. Your doctor can tell you about creams to make your skin feel better.
  • Cardioversions dont always bring back normal heart rhythms. If normal rhythms dont return, you may need medicines, a pacemaker or an implantable cardioverter defibrillator .

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