Why is Electrical Cardioversion contraindicated in AF and Digitalis Poisoning?
The mechanism of action of digitalis-like preparations based on inhibition of myocardial NA+/K+-ATPase as well as of cardiac conducting tissue. The inhibition of latter (conducting) is 2.5 greater than those of former (myocardial). This is why the main feature of digitalis intoxication are arrhythmias due to ectopic electric impulses and spontaneous depolarization (there is overloading of conducting system by Calcium as well as excess amounts of Noradrenaline released from sympathetic endings).

These metabolic changes in a case of digitalis intoxication could lead to irreversible ventricular arrhythmias after cardioversion - there are sporadic reports about this phenomenon. Based on these reports, it was thought that the use of digitalis during electrical cardioversion would provoke ventricular arrhythmias in patient even with clinically desirable concentration of digitalis.

In a study in patients with therapeutic nontoxic digitalis levels determined that these patients may safely undergo electrical cardioversion without reducing or withholding the dose of digitalis. Thus, the cardioversion is not contraindicated in a patient without signs of digitalis toxicity.

Although, the exact mechanism of the ventricular arrhythmias after cardioversion is not well understood, it is clear that mentioned above changes in electrolytes concentrations with electrical stimulation lead to premature beats overtaking restored sinoatrial pace. The rate of ventricular arrhythmias is in direct correlation with the level of the energy used for the cardioversion (this is why there is "pre-cardioversion" with low-energy pulses). Until these metabolic changes are not corrected, the resulting ventricular arrhythmias can be irreversible. This is why, digitalis intoxication is relative contraindication to electric cardioversion of atrial fibrillation/flatter.

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