Question For Cardiac Nurses

moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS · Dec 3, 2003

I got this from Web MD-

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Introduction

Medical Information

Your Information

Wise Health Decision

Credits

Should I try cardioversion for atrial fibrillation?

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

Cardioversion for atrial fibrillation can return your heart rate to a normal sinus rhythm. As long as you stay in normal sinus rhythm, your risk of stroke is reduced. However, atrial fibrillation often returns. Consider the following when making your decision:

If your atrial fibrillation is not caused by an underlying heart condition, cardioversion is often an effective way to restore your heart to a normal rhythm.

Cardioversion is less successful if you have had multiple recurrences of atrial fibrillation or if you have long-standing heart disease.

Most people with underlying heart disease eventually have persistent atrial fibrillation that does not remain in a normal rhythm despite cardioversion. These people can significantly reduce the risk of stroke and symptoms by taking anticoagulants and medications to control heart rate.

Medical Information

What is cardioversion?

There are two ways to convert your heart to a normal rhythm. They are:

Electrical cardioversion. An external defibrillator is used in electrical cardioversion. After a sedative is given, a doctor places metal paddles or patches to the chest wall. The paddles send an electric current to your heart, stopping it momentarily. When the heart resumes beating, it usually starts in a normal rhythm. Electrical cardioversion successfully restores normal sinus rhythm in 90% of people who have recent-onset atrial fibrillation.1

Chemical cardioversion. Antiarrhythmic medications, such as ibutilide, sotalol, procainamide, and amiodarone, convert your heart to a normal rhythm by reducing atrial excitability and stabilizing the heart muscle tissue. Chemical cardioversion may be used when electrical cardioversion or sedation is considered unsafe or inappropriate. It is less physically traumatic than electrical cardioversion, but it is also less effective. Antiarrhythmic medications also have many serious side effects.

How effective is cardioversion?

Electrical cardioversion successfully restores normal sinus rhythm in 90% of people who have recent-onset atrial fibrillation.1 Staying in a normal rhythm is more likely when the underlying cause is not heart disease. However, in most cases atrial fibrillation is caused by underlying heart disease and is highly likely to recur.

The chance of maintaining a normal rhythm is lower the longer you have had atrial fibrillation, and decreases to very low levels when atrial fibrillation has been present for more than a year.2

What are the risks of cardioversion?

Having a stroke is the most serious risk of cardioversion. Cardioversion may dislodge a blood clot in your heart, causing a stroke. However, this risk can be significantly reduced by the following precaution:

If your atrial fibrillation has lasted for more than 48 hours, your doctor will probably prescribe anticoagulants for several weeks before attempting cardioversion to reduce the risk of stroke. Or, your doctor may use transesophageal echocardiography to assess whether you have a clot in your heart that could cause a stroke. If the heart is clear of clots, cardioversion can be attempted. Anticoagulant medication is taken for 4 weeks after cardioversion.

Treatment with an intravenous anticoagulant, such as heparin, is recommended before cardioversion and oral anticoagulants for 3 to 4 weeks before cardioversion when atrial fibrillation has been present for more than 48 hours.3

Additionally, antiarrhythmic medications used before and after cardioversion or even the cardioversion itself may cause a life-threatening irregular heartbeat. Your doctor will be ready for this possibility and will be prepared to treat it.

What are the risks of not having cardioversion?

If you choose not to try cardioversion, you still will be at risk for problems from atrial fibrillation.

You may have heart palpitations, chest pain, or shortness of breath, especially during physical activity or emotional stress. You may also tire easily or have problems with weakness, confusion, dizziness, or fainting.

If you are not bothered by symptoms of atrial fibrillation, you doctor may prescribe medications to slow your heart rate and allow the atrial fibrillation to persist.

You will still probably need to take anticoagulant medications to decrease your risk of stroke. However, these medications increase your risk of developing a serious problem with bleeding. You will need to have your blood tested frequently while you are taking an anticoagulant.

If you need more information, see the topic Atrial Fibrillation.

Your Information

Your choices are:

Try cardioversion in an attempt to convert to a normal rhythm.

Do not have cardioversion; take medications to control heart rate, and take anticoagulants.

The decision whether to try cardioversion takes into account your personal feelings and the medical facts.

Reasons to try cardioversion

Reasons to not try cardioversion

Your atrial fibrillation is not related to underlying heart disease.

You have had only one episode of atrial fibrillation.

You have symptoms of atrial fibrillation that are bothersome, such as palpitations, or affect the quality of your life, such as shortness of breath with exertion.

If cardioversion was successful the first time but you reverted to atrial fibrillation after some time, you may want to try it again.

Are there other reasons you might want to try cardioversion?

You have had several atrial fibrillation episodes and have underlying heart disease.

You do not have any symptoms of atrial fibrillation.

You have tried cardioversion once or twice and atrial fibrillation recurred.

Are there other reasons you might not want to try cardioversion?

These personal stories may help you make your decision.

Wise Health Decision

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about cardioversion. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I do not have an underlying heart condition. Yes No Unsure

I have recently had episodes of atrial fibrillation. Yes No Unsure

I have not tried cardioversion or only tried it once. Yes No Unsure

I have fainting spells when my heart is beating irregularly. Yes No Unsure

I feel better when my heart rhythm is normal. Yes No Unsure

Use the following spaces to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to try or not try cardioversion.

Check the box below that represents your overall impression about your decision.

Leaning toward trying cardioversion

Leaning toward NOT trying cardioversion

Return to the topic Atrial Fibrillation.

References

1Pelosi F, Morady F (2001). Evaluation and management of atrial fibrillation. Medical Clinics of North America, 85(2): 225-245.

2Van Gelder IC, et al. (2002). A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. New England Journal of Medicine, 347(23): 1834-1840.

3Fuster V, et al. (2002). ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences. Journal of the American College of Cardiology, 38: 1266i-1266lxx.

Credits

Author Nancy Reid

Editor Geri Metzger

Associate Editor Lila Havens

Associate Editor Tracy Landauer

Primary Medical Reviewer Patrice Burgess, MD

- Family Medicine

Specialist Medical Reviewer Laurence Epstein, MD

- Cardiac Electrophysiologist

neneRN, BSN, RN · Dec 3, 2003

First off, I'm hoping your husband's HR was not 150s when he left the MD office! Was the ventricular response in the 150s or the flutter rate? I'm assuming if he was okay to leave then the flutter rate was 150, and his ventricular response was in the 50s, as its common to have a 3 to 1 flutter?

Rapid A flutter is like rapid A fib in the sense that it puts you at risk for clot formation in the atria, which can then travel, leading to MI, CVA, etc.

We tend to try meds first-usually cardizem IV, before going to cardioversion, but some of the cardiologists are more aggressive and tend to go right for the shocking. The length of time the tachycardia is sustained and whether or not the pt is on blood thinners also factor in the decision of how to treat.

The biggest risk of the procedure would be for the pt to be shocked into another arrythmia. Just curious, does your husband have an AICD with the pacemaker?

Good luck tomorrow.

olympiad27 · Dec 3, 2003

I have several thoughts here: First your husband should not be on two different beta blockers. Second, beta blockers work (in this instance) to control/slow the rate, not convert the rhythm. You did not mention whether or not he was on an antiarrhythmic (he should be) in order to cardiovert him. If he is young & healthy he may tolerate a rate of150 for awhile but otherwise he will become symptomatic at that rate. Some people become quite symptomatic. He should be on aspirin to reduce the risk of stroke although that is not as much of a consideration in atrial flutter (since there is organzed atrial activity) as in a fib. But frequently people go from aflutter to afib. Not always. Anyways those are my thoughts.

Jay-Jay, RN · Dec 3, 2003

Thank you for the info, everyone. Much appreciated! And Moonshadeau...wow! What a terrific website!

My husband does go from a-flutter to a-fib. The flutter is new, the a-fib is not. It's been happening off and on for about 2 years now. Aside from fatigue, shortness of breath, and occasional dizzy spells, when the flutter is at its worst, he is mostly asymptomatic. Of course, he's not in flutter all the time.

He's on digoxin to help the rhythm, but refuses to take amiodarone, due to all the side effects.

As for the beta blockers, he's on Monocor and metoprolol. Monocor has some antiarrhythmic properties, as well as being a beta blocker.

And yes, the base ventricular rate seems to be about 60, when he's in sinus rhythm.

live4today, RN · Dec 3, 2003

Jay-Jay, I will be thinking healing thoughts tomorrow for your husband. I pray everything will turn out fine for him. :kiss

SCNuttyMeg · Dec 3, 2003

I work on a cardiac floor and hand out amiodarone like its candy. He really needs to take it, it usually converts the rhythm back to SR. The main effect ive seen is extreme nausea if not taken with food. I read that someone said it can cause a stroke this is true but where i work they do a TEE to see if there are any clots before a cardioversion is done so a stroke can be prevented. Is your husband having one of those done? It is good that he is on coumadin to try to preven clots. Even after cardioversion ive seen patients convert back to the abnormal rhythm. Hope everything goes well :)

chris_at_lucas_RN, RN · Dec 3, 2003

Unfortunately, there was no time to ask her questions, so I'm turning to my nursing buddies here

Jay-Jay, MAKE HER GIVE YOU THE TIME.

Cadillacs and Fords notwithstanding, getting some of your questions answered would certainly reduce the stress caused by not knowing.

Good to have this BB, but nothing substitutes for time. He was well enough to leave the office, it wasn't like he was rushed by helicopter for openheart someplace (thank God), then the cardio had the time.

She just didn't give it to you and your DH.

Peace--and prayers....