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©2013 UpToDate ® Print Email ACC/AHA/ESC guideline summary: Antiarrhythmic drug enhancement of direct-current (DC) cardioversion in atrial fibrillation (AF) Class IIa - The weight of evidenceor opinion is in favor of the usefulness of the following approaches tothe pharmacologic enhancement of DC cardioversion in AF •  Pretreatment with amiodarone, flecainide, ibutilide, propafenone, or sotalol, which may also prevent recurrent AF. •  In patients who relapse after successful cardioversion prior to repeat DC cardioversion. Class IIb - The weight of evidenceor opinion is less well established for the usefulness of the followingapproaches for the pharmacologic enhancement of DC cardioversion in AF •  Among patients with persistent AF, beta blockers, disopyramide, diltiazem, dofetilide, procainamide, or verapamil; the ability of these drugs to increase the success of DC cardioversion or to prevent early AF recurrence is uncertain. •  Out-of-hospital initiation of antiarrhythmic drugs in patients without heart disease. •  Out-of-hospital initiation of antiarrhythmic drugs in patients with certain forms of heart disease if the safety of drug has been verified for the patient. Data from Fuster, V, Ryden, LE, Cannom, DS, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation). J Am Coll Cardiol 2006; 48:e149.