Franken RA et al. Atrial fibrillation in the elderly 97 Figure 5. Sequence of treatment of AF. ACE: angiotensin converting enzyme; AF: atrial fibrillation; ARB: Angiotensin receptor blocker; ECG: electrocardiogram; PUFA: polyunsaturated fatty acids.[65] before AF cardioversion (Evidence Level B). (2) If no clots are identified, start fractionated heparin administration with initial bolus injection followed by continuous infusion with adjusted dose to prolong APTT 1.5 to 2 times the control value maintained until oral coagulation with INR higher than 2 is achieved (Evidence Level B). There are still insufficient data to recommend low molecular weight heparin (Evidence Level C). (3) Patients with clots identified by transesophageal echocardiogram should have oral anticoagulation (INR between 2 and 3) three weeks before. (4) Anticoagulation in atrial flutter patients submitted to cardioversion using the same protocol used for AF. 4.3 Anti arrhythmic drugs for pharmacological cardioversion of AF Class I: (1) Oral or intravenous propafenone for pharma- cological AF reversion, in the absence of structural heart disease (Evidence Level A). This drug should be avoided in patients aged above 80 years old. (2) Intravenous amiodarone for pharmacological AF reversion in the presence of moderate or severe ventricular dysfunction (Evidence Level A). Class II A: (1) Intravenous amiodarone for pharmaco- logical AF reversion in the absence of moderate or severe ventricular dysfunction (Evidence Level A). (2) Single oral 600 mg dose of propafenone for pharmacological paroxysmal or permanent AF reversion outside the hospital, provided the treatment has already been shown to be effective and safe during hospital stay, in patients without sinus node or atrioventricular dysfunction, branch blockade, QT interval prolongation, Brugada syndrome, or structural heart disease. Before starting the antiarrhythmic medication, beta-blocker or non-dihydropiridinic calcium channel blockers should be administered to prevent fast atrial conduction if atrial flutter occurs (Evidence Level C). Class III: (1) digoxin and sotalol for pharmacological AF reversion (Evidence Level A); (2) Quinidine started outside the hospital for AF pharmacological reversion (Evidence Level B). 5 Electrical cardioversion Class I: (1) AF with fast ventricular rate without immediate response to pharmacological measures, or followed by myo- cardial ischemia, hypotension, angina, or HF (Evidence Level C). (2) AF associated to ventricular pre-excitation with very fast tachycardia or hemodynamic instability (Evidence Level B). (3) Very symptomatic AF even without hemodynamic instability. In cases of early AF recurrence, cardioversion should be repeated after the administration of antiarrhythmic drugs (Evidence Level C). CLASS III: (1) Frequent repetition of electrical cardio- version in patients with relatively short sinus rhythm periods due to AF recurrence, in spite of prophylactic therapy with antiarrhythmic drugs; (2) electrical cardioversion in patients with digitalic intoxication or hypo-potassemia (Evidence Level C). 5.1 Improved electrical cardioversion effectiveness with antiarrhythmic drugs CLASS II A: (1) Pretreatment with amiodarone, propafenone or sotalol to increase electrical CV success aiming at preventing AF recurrence (Evidence Level C); (2) Prophylactic antiarr- http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology