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A patient with known or suspected atrial fibrillation (AF) is a candidate for a pharmacological cardioversion. If the patient has complications (coronary artery disease, congestive heart failure, diabetes, and hypertension), he/she is a candidate for a cardioversion. An asymptomatic patient is a candidate for a pharmacological cardioversion, if the patient has AF, or for a nonpharmacological cardioversion, if the patient is in atrial standstill. The decision to cardiovert is based on the evaluation of the ischemic risk, which is the only one atrial fibrillation-related complication.
The main reason to select a cardioversion in a patient with AF is to restore sinus rhythm. For a pharmacological cardioversion, it is still an open question which drug and dose is the most effective and safest one. In patients without complications, the choice is mainly based on the risk of ischemic events, represented by the CHADS2 score.
The first pharmacological cardioversion was performed in the 1950s, using digitalis (DIG) and procainamide (PRO). This treatment became widespread with the development of amiodarone (AMIO). In recent years, in the management of patients with AF, studies have found a cardioversion rate of 5-30% with DIG or PRO, and a rate of 2-8% with AMIO.
The most important limitation of DIG and PRO is that they induce conduction abnormalities. The other limitation is that, if the dose is high, AMIO is considered to be the most effective treatment.
The risk of ischemic events in patients undergoing a pharmacological cardioversion is relatively high. The number of ischemic events can be defined as a serious complication.
In the study by McCormick et al., the ischemic events ranged from 2 to 11%. In one study, for the CHADS2 score, the rates of ischemic events were: CHADS2 0, 1-2 and > 2, respectively: 1.4%, 3.4%, and 7.1%. Recently, an interesting treatment has been the identification of an effective treatment for AF without the ischemic events.
In 2014, the results of the AC