ESC 2024 Recommendations for Pharmacological Cardioversion of Atrial Fibrillation

✅ When to use pharmacological cardioversion (PCV)

PCV is intended for hemodynamically stable patients with AF — unstable patients still generally merit electrical cardioversion. 

The decision between PCV vs electrical cardioversion should also reflect patient preference, underlying heart disease / structural heart disease, and risk factors including thromboembolism. 

Before any rhythm control (including PCV), the patient’s thromboembolic risk must be assessed; and anticoagulation should be started (or continued) appropriately. 

For patients with AF of unclear duration > 24 hours, PCV (or any cardioversion) is not recommended unless there has been “therapeutic anticoagulation for ≥ 3 weeks” or a transesophageal echocardiography (TOE) has excluded atrial thrombus. 

After cardioversion, oral anticoagulation (OAC) should be continued in nearly all patients for at least 4 weeks — and long-term in those with thromboembolic risk factors, regardless of whether sinus rhythm is maintained. 

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💊 Which antiarrhythmic drugs and when (per ESC 2024)

From the guideline’s “Recommendations for pharmacological cardioversion of AF” table. 

Drug / Strategy Indication / Comments

Intravenous (IV) Flecainide or IV Propafenone Recommended (Class I, Level A) in recent-onset AF, if no severe structural heart disease (no severe LVH / HFrEF / CAD). 

IV Vernakalant Recommended (Class I, Level A) for recent-onset AF — except when there is recent ACS, HFrEF, or severe aortic stenosis. 

IV Amiodarone Recommended (Class I, Level A) when there is structural heart disease (e.g. severe LVH, HFrEF, or CAD), acknowledging that conversion may be delayed. 

“Pill-in-the-pocket” approach (single high oral dose of flecainide or propafenone) Should be considered (Class IIa, Level B) in selected patients with infrequent paroxysmal AF, provided prior safety and efficacy testing in a monitored environment; exclude those with severe structural disease. 

When PCV is not recommended PCV is not recommended in patients with sinus-node dysfunction, AV-conduction disturbances, or prolonged QTc (> 500 ms) — unless risks (pro-arrhythmia / bradycardia) have been carefully considered. 

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🔎 Practical and Safety Considerations (2024 Key Messages)

PCV does not require fasting, sedation, or general anaesthesia, which can make it an attractive option versus electrical cardioversion. 

Timing is critical: the shorter the time since AF onset, the greater the chance of successful pharmacological conversion. 

Regardless of sinus rhythm restoration, anticoagulation should follow — based on individual thromboembolic risk factors (not solely on whether sinus rhythm is achieved). 

PCV offers a non-invasive alternative but is less effective than electrical cardioversion. 

The overall strategy for AF management per 2024 guidelines emphasizes: risk-factor and comorbidity management; stroke prevention; and careful shared decision-making when choosing rate vs rhythm control, PCV vs electrical cardioversion vs ablation. 

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✅ How 2024 ESC Update Changed/Clarified Things (vs prior versions)

The classification and timing thresholds for when cardioversion (pharmacological or electrical) is acceptable have been refined: the 2024 guideline emphasizes safety first, especially regarding anticoagulation or TOE before cardioversion if AF duration > 24 h. 

The need to base long-term rhythm control (and cardioversion) decisions not only on AF per se, but on symptoms, quality of life, comorbidities, and patient preference — not all patients with AF need rhythm control. 

Reinforcement that anticoagulation decision is independent of rhythm outcome: even if sinus rhythm is restored, OAC should be continued per thromboembolic risk. 

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🧠 Clinical Implications & What to Watch for in Practice

When you are evaluating a patient for PCV, first ensure hemodynamic stability, decide if PCV is preferred vs electrical — taking into account structural heart disease, comorbidities, and patient preference.

Always assess thromboembolic risk (e.g. with the new simplified CHA2DS2‑VA score) before converting; ensure appropriate anticoagulation or perform TOE if needed — especially if AF duration > 24 h. 

Choose the antiarrhythmic carefully: for patients without significant structural disease — flecainide, propafenone, or vernakalant; for those with heart failure / structural disease — amiodarone may be safer albeit slower.

Inform patients: PCV may avoid hospitalization (no anaesthesia), but success rates vary — and anticoagulation remains essential.

Integrate PCV into a comprehensive AF management plan: rhythm control is only one pillar; risk-factor modification, rate control (when needed), and stroke prevention remain central.