Management of Atrial Fibrillation

In a patient with a probable first episode of AF an attempt should be made to restore sinus rhythm. However, if AF has been present for >48 hrs – as seems very likely in this case – it is necessary to anticoagulate before cardioversion, unless it can be documented by trans-oesophageal echocardiography (TOE) that the left atrium is free of thrombus. If this were the case, then cardioversion within the next 24 hours would be the preferred management option, with warfarinisation for a month afterwards (which is a high risk period for thromboembolism).