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Optimal practice review: recommendation reminders detail

Recommendation reminder 1: An antiarrhythmic drug is not required to maintain sinus rhythm in patients with persistent AF in whom a precipitant (such as chest infection or fever) has been corrected and cardioversion has been performed successfully, providing there are no risk factors for recurrence.

Guidance:Atrial fibrillation
Date issued:June 2006

Atrial fibrillation (AF) is a condition that affects the heart. It occurs when the electrical impulses controlling the heartbeat become disorganised, so that the heart beats irregularly and too fast. This causes an irregular pulse resulting in the heart not being able to efficiently pump blood around the body. This may cause symptoms such as palpitations, chest pain or discomfort, shortness of breath, dizziness and fainting. Severe symptoms can be life threatening and require immediate treatment. However, many people with AF have no or only mild symptoms.

AF may increase the risk of blood clots because when the heart beats irregularly, the blood does not flow properly through the heart and the rest of the body. People with AF may need medication to reduce or prevent this risk.

Persistent AF is a type of AF that lasts for longer than 7 days and needs treatment called ‘cardioversion’ to help the heart return to beating normally. Cardioversion uses either medicine (pharmacological cardioversion) or electric shock (electrical cardioversion), or sometimes both, to help the heart return to its normal (sinus) rhythm.  

Pharmacological cardioversion is most likely to be used within the first 48 hours of AF starting. Medicines (called ‘antiarrhythmic drugs’) are used to help the heart return to a normal rhythm. If AF has lasted longer than 48 hours then electrical cardioversion should usually be used. Sometimes antiarrhythmic drugs are used together with electrical cardioversion to help maintain a regular heartbeat after the procedure.

Factors that should be considered when deciding whether to try to control heart rate or heart rhythm in patients with persistent AF include whether they have heart failure, coronary artery disease or structural heart disease, their age, whether cardioversion is suitable, whether they can tolerate the medicine’s side effects, and which medicines will work for their specific condition.

The NICE Guideline Development Group (GDG) reviewed the evidence comparing patients who maintained a normal heart rhythm after cardioversion with those who experienced another AF. These studies showed that cardioversion was most likely to be successful in patients who had recent onset AF, no underlying structural heart disease, or AF secondary to an identified cause (precipitant) that had been successfully treated or corrected.

The GDG also noted that, in UK clinical practice, antiarrhythmic drugs are not usually used to maintain sinus rhythm after cardioversion in cases of a first-detected episode of AF, especially if AF is secondary to a precipitant that has since been corrected.

NICE therefore recommends that an antiarrhythmic drug need not be used to maintain sinus rhythm in patients with persistent AF in whom a precipitant (such as chest infection or fever) has been corrected and cardioversion has been performed successfully, providing there are no risk factors for recurrence.

This page was last updated: 20 May 2009

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.