**9.1 Use of amiodarone for PCV**

IV: Infused primarily 150 mg/10 minutes. Then 1 mg/min is infused for 6 hours, 0.5 mg/min for 18 hours. The maximum total dose is 10 g. It can be continued orally (100–200 mg/day).

Can the patients terminate AF themselves? Yes. One approach that can also be seen as a variant of the rhythm control strategy is that individuals with infrequent attacks are given a certain training, and these individuals immediately receive PCV by taking the appropriate medication right next to them. This approach, also known as the 'drug in the pocket' concept, can be used very beneficially in selected patient groups.

Flecainide (95%) and ibutilide (76%) were found to be the most effective drugs used for PCV in 376 patients with AAF in the ED [19]. Amiodarone, digoxin and diltiazem have very low success rates. A striking result is an observation that patients presenting with low blood pressure and who had a short period of time from the onset of AF to treatment revert to sinus rhythm with higher success.

#### **9.2 Procedure recommendation**

For PCV, propafenone from group IC can be used for conversion of AF to NSR. For this purpose, 600 mg propafenone (4 150 mg tb) is administered orally at a time and the patient is expected to convert within a few hours. This procedure is only recommended in the hospital.

ECG monitoring is recommended because a prolonged period of asystole, rarely syncope or prolonged bradyarrhythmias may occur during 'successful' conversion.


#### **Table 4.**

*Sedatives and narcotics, doses, duration of action and expected side effects for sedoanalgesia used in ECV procedure in the ED. the drugs are used by an experienced emergency physician or anaesthesiologist, titrated with respect to the response of the patient.*

*Recognition and Management of Supraventricular Arrhythmias and Atrial Fibrillation… DOI: http://dx.doi.org/10.5772/intechopen.106182*

#### **10. Synchronized/simultaneous cardioversion**

When midazolam and fentanyl are administered at recommended doses and under appropriate conditions, the side effect profile is at an acceptable level (**Table 4**). In the presence of signs of opioid overdose that may occur, albeit very rarely, naloxone should be used by titrating at the recommended doses in the table. Ketamine, which is widely used for sedoanalgesia in other indications, is not preferred in this group of cases as it may have tachycardic effects.

#### **11. Rate control**

Rate control strategy is a treatment approach preferred in patients with AF attacks thought to recur especially in those with structural heart disease, coronary artery disease, and advanced age. It is aimed to improve the symptoms by reducing the heart rate. Patients who are not selected/unsuitable for ECV are evaluated in the rate control group.

Antiarrhythmic agents such as beta-blockers (metoprolol), calcium channel blockers (diltiazem), and amiodarone are widely used for rate control. The serious toxic effects of amiodarone on many organs and systems limit its use. Digoxin is also a frequently used agent in the past, but it is rarely recommended in contemporary practice.

IV beta-blocker and nondihydropyridine CCB (diltiazem) is the drug of choice for acute rate control in AF with rapid ventricular response (Class IIa, LOE A).

Digoxin and amiodarone can be used for rate control in patients with CHF + AF. However, after the use of amiodarone, the risk of return to sinus rhythm and resultant embolization should be taken into account.

A large complex, irregularly irregular rhythm may reflect an AF with pre-excitation (WPW/LGL). Expert consultation should be obtained early.


Procainamide is a widely used agent in most parts of the world for PCV. In a study in which the 'Ottawa Aggressive Protocol' put forward in Canada in the last decade was tested, 660 AAF (4.9% AFL) cases were taken as a cohort [20]. If it could not be understood whether the AAF attack lasted longer than 48 hours, the presence of mural thrombus was examined by TEE. Initially, IV procainamide was given to all cases, and a conversion rate of 58.3% was achieved. ECV procedure was performed in all remaining 243 cases, it was successful in 91.7% of them. Recurrent attacks were

observed in 8.6% of the cases within 7 days. The patients stayed in the ED for an average of 4.9 hours (3.9 hours in patients with PCV, 6.5 hours in patients with ECV) and 96.8% were discharged from the ED.

### **12. Antithrombotic-antiaggregant treatment in patients with AF**

In AF cases in which effective contractions do not occur, blood may undergo stasis and turn into clots, especially in the left atrium. This phenomenon is clearly seen in AF patients lasting for 48 hours and older. The delivery of these clots to the arterial circulation via the aorta occurs most often during the conversion of AAF to normal sinus rhythm, so it is important to demonstrate that there is no clot for ECV/PCV of chronic AF. Arterial circulation may stop in any part of the body with this event called thromboembolism of mural thrombi. Apart from AF, cancer, haematological problems, coronary artery disease, heart failure and ventricular aneurysms can pave the way to thrombus formation. Acute arterial occlusion, renal infarction, acute mesenteric embolism may occur, but the most important morbidity is that it causes cerebral thromboembolism or stroke.

Warfarin (Coumadine) and heparin are agents that prevent fibrin formation, they are in the anticoagulant group. Acetyl salicylic acid (ASA, Aspirin) and clopidogrel (Plavix) or ticagrelor (Brilinta) are antiaggregant or antiplatelet agents. The combined use of P2Y12 inhibitor and ASA is called dual antiplatelet treatment (DAPT). Among these, warfarin prevents clot formation in the most efficient way, provides full effectiveness within a few days after its use, and requires monitoring with prothrombin time (PT) and international normalized ratio (INR) level every 4–8 weeks. In recent years, the 'triple antiplatelet therapy' (TAPT) method has been in question, with the addition of an agent from the DOAC group (such as dabigatran/rivaroxaban) to the DAPT regimen. Recent reports pointed out that TAPT strategy may be associated with higher bleeding episodes and mortality compared to a DAPT regimen—the combination of an anticoagulant and a P2Y12 inhibitor [21].

As of the update in January 2019, the following recommendations are in effect: [22].


## **13. Does AF in my patient cause a cerebrovascular accident?**

Yes, it can. In NVAF, the CHA2DS2-VASc score and risk criteria have been used in recent years instead of the CHADS2 criteria in 2001 in order to predict this more clearly (**Tables 5** and **6**).

*Recognition and Management of Supraventricular Arrhythmias and Atrial Fibrillation… DOI: http://dx.doi.org/10.5772/intechopen.106182*


#### **Table 5.**

*CHA2DS2-VASc score and risk criteria.*


#### **Table 6.**

*CHA2DS2-VASc score and annual stroke risks with relevant treatment recommendations.*

## **14. How is emergency anticoagulation done before ECV?**

If PCV or ECV is planned in a patient with AF that is thought to last longer than 48 hours, one of the following three regimens should be started:


When no thrombus is seen and ECV/PCV is successful, anticoagulation is continued for another 4 weeks (target INR, 2.5). If a thrombus is seen, ECV/PCV is delayed. TEE should be repeated before each ECV attempt.

At the earliest period in a hemodynamically unstable case with a suspected ECV


After successful cardioversion, VKA/warfarin (target INR, 2.5) is continued for at least 4 weeks. Long-term anticoagulation will depend on the patient's risk status, previous cardioversion procedures or another embolism status. For example, maintenance with rivaroxaban, one of the NOACs, is more suitable for those who have had a pulmonary embolism.

The above regimens are also valid in cases with flutter (Grade 2C).

The following agents were found to be effective in cases where treatment with OAC was considered:



**Table 7.** *HAS-BLED score.* *Recognition and Management of Supraventricular Arrhythmias and Atrial Fibrillation… DOI: http://dx.doi.org/10.5772/intechopen.106182*

