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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e72 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation score,22,43 especially in those with CHA2DS2-VASc score ≥2 in the absence of anticoagulation.22 7 Retrospective observational data from the FinCV (Finnish CardioVersion) study noted low incidence of 30-day pericardioversion thromboembolic event rate of 0.4% in patients with AF with CHA2DS2- VASc of 0 to 122 or 0.3% in patients with duration of <12 hours of AF.21 Other retrospective studies have similarly demonstrated low pericardioversion thromboembolic risks in patients with CHA2DS2-VASc score of 0 to 1.42 The combination of CHA2DS2- VASc of 0 to 1 in conjunction with duration of <12 hours of AF may identify a population at particularly low risk for pericardioversion thromboembolism. 8.2.2 Electrical Cardioversion Recommendations for Electrical Cardioversion Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 C-LD 1 In patients with hemodynamic instability attributable to AF, immediate electrical cardioversion should be performed to restore sinus rhythm.1 1 B-R 2. In patients with AF who are hemodynamically stable, electrical cardioversion can be performed as initial rhythm-control strategy or after unsuccessful pharmacological cardioversion.2 1 C-LD 3 In patients with AF undergoing electrical cardiover- sion, energy delivery should be confirmed to be synchronized to the QRS to reduce the risk of inducing VF.3 2a B-R 4 For patients with AF undergoing elective electrical cardioversion, the use of biphasic energy of at least 200 J as initial energy can be beneficial to improve success of initial electrical shock.4,5 2a B-NR 5 In patients with AF undergoing elective cardiover- sion, with longer duration of AF or unsuccessful initial shock, optimization of electrode vector, use of higher energy, and pretreatment with antiarrhythmic drugs can facilitate success of electrical cardioversion.5–9 2b C-LD 6 In patients with obesity and AF, use of manual pressure augmentation and/or further escalation of electrical energy may be beneficial to improve success of electrical cardioversion.10 Synopsis Electrical cardioversion is a strategy for acute rhythm control. Compared with pharmacological cardioversion alone, electrical cardioversion with synchronized direct current cardioversion is more rapid and efficacious for restoring sinus rhythm from AF.1,11,12 Given rapidity and efficacy, electrical cardioversion is the treatment of choice for patients with hemodynamically unstable AF. In hemodynamically stable patients with AF planned for acute rhythm control, electrical cardioversion can be performed as an initial strategy or after unsuccessful pharmacological cardioversion.2,6,13,14 Electrical cardioversion is favored over pharmacological cardioversion when the patient is able to tolerate sedation, desires more immediate rhythm conversion, or has failed or not met candidacy for pharmacological cardioversion. Although electrical cardioversion may achieve acute restoration of sinus rhythm, durability of sinus rhythm may be influenced by ongoing acute conditions, LA size, duration of the history of AF and/or specific episode, and comorbidities.14 In patients with a longer duration of AF, immediate recurrence of AF, a previous unsuccessful electrical cardioversion, or a desire to employ all reasonable efforts to avoid an AF recurrence, pretreatment antiarrhythmic drugs and subsequent continuation to facilitate success of acute cardioversion and promote maintenance of sinus rhythm postcardioversion6,8,9 may be pursued in the context of SDM with the patient. Optimization of energy delivery, electrode vector, and reduction of transthoracic impedance with manual pressure augmentation may also improve success of electrical cardioversion.5–10 Recommendation-Specific Supportive Text 1. In patients with hemodynamically unstable AF, immediate electrical cardioversion with synchronized direct current cardioversion is the treatment of choice. Direct data on emergency cardioversion of hemodynamically unstable patients is limited because of the emergency circumstances of the clinical context. Data on direct current cardioversion of AF in hemodynamically stable patients demonstrate high success rate of restoring sinus rhythm with direct current cardioversion.1,11,15–18 Electrical cardioversion is rapid. Electrical cardioversion alone is more effective than pharmacological cardioversion alone.1,11,12 2 Goals of rhythm control are summarized in Section 8.1 (“Goals of Therapy With Rhythm Control”). Real-world data support both electrical cardioversion and pharmacological cardioversion as acceptable, safe, and efficacious methods for acute rhythm control.6,13,14 Electrical cardioversion is more effective than pharmacological cardioversion alone1,11 but involves the trade-off of requiring sedation.19 In patients with hemodynamically stable AF of recent onset, the RAFF2 (Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation) study demonstrated high success of restoration of sinus rhythm with either an upfront electrical cardioversion strategy or a stepwise strategy with initial pharmacological cardioversion and then direct current cardioversion if the pharmacological intervention did not restore sinus rhythm.2 In patients with unsuccessful pharmacological cardioversion, instead of switching to another antiarrhythmic drug (and with concerns for potentiation of adverse effects such as QT prolongation or bradycardia), electrical cardioversion should be pursued as next Downloaded from http://ahajournals.org by on October 7, 2026