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 cardioversion, 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 cardioversion, 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