Rate control vs rhythm control in new-onset AF — when do you choose cardioversion?

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For hemodynamically stable new-onset AF (<48 hours duration), either rate control or rhythm control is acceptable. Key decision points: IMMEDIATE ELECTRICAL CARDIOVERSION is indicated when: - Hemodynamic instability (hypotension, acute pulmonary edema, severe chest pain) - Pre-excitation (WPW + AF) — IV amiodarone/digoxin are contraindicated - Acute coronary syndrome precipitated by rapid AF For this stable patient with AF onset <48 hours: APPROACH: Rhythm control is reasonable given young age, new-onset, and structural normality. If duration is confirmed <48 hours: - Can cardiovert without prior TEE (low thrombus risk) - Start anticoagulation BEFORE cardioversion (LMWH or DOAC) - Options: electrical (synchronized DC cardioversion at 200J biphasic — preferred, >90% success) or pharmacological (IV flecainide 2mg/kg or oral propafenone "pill in pocket") - After cardioversion: continue anticoagulation for at least 4 weeks (post-cardioversion stunning risk), then reassess based on CHA2DS2-VASc (score 3 here → lifelong DOAC) Rate control targets: resting HR <110 bpm (lenient) or <80 bpm (strict — for symptomatic patients). Use metoprolol IV or diltiazem IV. AFFIRM trial (2002) showed rate = rhythm control for mortality, but more recent EAST-AFNET 4 (2020) showed early rhythm control reduces CV outcomes in recently diagnosed AF — supporting rhythm control in this case.