ACLS Cardioversion Recommendations

Indications for Immediate Cardioversion

The American Heart Association recommends performing immediate synchronized cardioversion for any tachyarrhythmia causing hemodynamic instability, including acute altered mental status, ischemic chest pain, acute heart failure, hypotension, or shock that persists despite adequate airway and breathing support, with a Class I Recommendation 1, 2
The American College of Cardiology suggests providing sedation in conscious patients before cardioversion, but do not delay the procedure if the patient is critically unstable, with a strength of evidence of Class I 1
For atrial fibrillation or atrial flutter with hemodynamic instability, the American College of Cardiology recommends cardioverting immediately without waiting for anticoagulation if duration is less than 48 hours, with a strength of evidence of Class I 3, 4

The European Society of Cardiology states that direct current cardioversion is mandatory for sustained VT with hemodynamic instability, with a Class I, Level C recommendation 5
For wide-complex tachycardia in hemodynamically stable patients, the European Society of Cardiology recommends electrical cardioversion as the first-line approach, with a strength of evidence of Class I 5
The European Society of Cardiology advises starting defibrillation at maximum output for cardiac arrest due to ventricular tachyarrhythmias, with a strength of evidence of Class I 5

The American Heart Association recommends synchronized cardioversion for hemodynamically unstable SVT when vagal maneuvers or adenosine are ineffective or not feasible, with a Class I, Level B-NR recommendation 6
For stable SVT, the American Heart Association suggests cardioversion when pharmacological therapy is ineffective or contraindicated, with a Class I, Level B-NR recommendation 6

The American College of Cardiology recommends requiring therapeutic anticoagulation for at least 3 weeks before and 4 weeks after cardioversion for AF/atrial flutter ≥48 hours or unknown duration, with a Class I, Level B recommendation 3, 4, 7
For AF/atrial flutter >48 hours requiring immediate cardioversion due to hemodynamic instability, the American College of Cardiology advises administering IV heparin bolus followed by continuous infusion, then oral anticoagulation for at least 4 weeks post-procedure, with a Class I, Level C recommendation 3, 4, 7

The American Heart Association recommends using synchronized mode for all organized rhythms to avoid delivering shock during vulnerable period of cardiac cycle, with a strength of evidence of Class I 1, 2
The European Society of Cardiology suggests ensuring proper electrode placement, ideally at least 8 cm from ICD generator if present, with a strength of evidence of Class I 5

The American College of Cardiology recommends pretreatment with amiodarone, flecainide, ibutilide, propafenone, or sotalol to enhance cardioversion success and prevent early AF recurrence, with a Class IIa, Level B recommendation 3, 7
The European Society of Cardiology suggests that IV amiodarone may facilitate defibrillation and prevent VT/VF recurrences in acute situations, with a strength of evidence of Class I 5

The American College of Cardiology states that electrical cardioversion is contraindicated in digitalis toxicity or hypokalemia, with a Class III, Level C recommendation 3
The American Heart Association advises not using verapamil for wide-complex tachycardias unless known to be supraventricular origin, with a Class III, Level B recommendation 1

The American College of Cardiology recommends never delaying cardioversion in hemodynamically unstable patients to obtain anticoagulation when AF duration is uncertain but instability is present, with a strength of evidence of Class I 3, 4
The American Heart Association suggests ensuring adequate sedation in conscious patients to minimize discomfort and patient movement during shock delivery, with a strength of evidence of Class I 1