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Kukendrarajah K, Ahmad M, Carrington M, Ioannou A, Taylor J, Razvi Y, Papageorgiou N, Mead GE, Nevis IF, D'Ascenzo F, Wilton SB, Lambiase PD, Morillo CA, Kwong JS, Providencia R. External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta-analysis. Cochrane Database Syst Rev 2024; 6:CD013255. [PMID: 38828867 PMCID: PMC11145740 DOI: 10.1002/14651858.cd013255.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion). OBJECTIVES To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index-Science (CPCI-S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. SELECTION CRITERIA We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to collect data and performed a network meta-analysis using the standard frequentist graph-theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption. MAIN RESULTS We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy-nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow-up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low-certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled. AUTHORS' CONCLUSIONS Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method.
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Affiliation(s)
| | - Mahmood Ahmad
- Department of Cardiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | | | - Adam Ioannou
- Royal Free London NHS Foundation Trust, London, UK
| | - Julie Taylor
- Institute of Health Informatics Research, University College London, London, UK
| | - Yousuf Razvi
- Department of Cardiology, Royal Free Hospital, London, UK
| | | | - Gillian E Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Immaculate F Nevis
- Health Economics and Outcomes Research, ICON plc, Blue Bell, Philadelphia, USA
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Internal Medicine, University of Turin, Turin, Italy
| | - Stephen B Wilton
- Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Pier D Lambiase
- Centre for Cardiology in the Young, The Heart Hospital, University College London Hospitals, London, UK
| | - Carlos A Morillo
- Department of Cardiac Sciences, Cumming School of Medicine, Foothills Medical Centre, Calgary, Canada
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Rui Providencia
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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Morin DP, Aymond JD. Ohm My Goodness! Thoracic Impedance, Its Predictors, and How It Relates to Cardioversion. Am J Cardiol 2024; 214:182-183. [PMID: 38181863 DOI: 10.1016/j.amjcard.2023.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/17/2023] [Indexed: 01/07/2024]
Affiliation(s)
- Daniel P Morin
- Department of Cardiology, Ochsner Medical Center, New Orleans, Louisiana; Department of Cardiology, University of Queensland Ochsner Clinical School, New Orleans, Louisiana.
| | - Joshua D Aymond
- Department of Cardiology, Ochsner Medical Center, New Orleans, Louisiana
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Asad ZUA, Imran S, Parmar M, Bajwa A, Truong D, Agarwal S, Ghani A, Clifton S, Reese J, Khan MS, Munir MB, DeSimone CV, Sivaram C, Jackman WM, Po S, Stavrakis S, Al-Khatib SM. Antero-lateral vs. antero-posterior electrode position for cardioversion of atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials. J Interv Card Electrophysiol 2023; 66:1989-2001. [PMID: 36929367 DOI: 10.1007/s10840-023-01523-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Multiple randomized controlled trials (RCTs) have compared the success of antero-lateral vs. antero-posterior electrode position for cardioversion of atrial fibrillation (AF). However, due to small sample size and conflicting results of these RCTs, the optimal electrode positioning for successful cardioversion remains uncertain. METHODS A systematic search of MEDLINE and EMBASE was conducted. Outcomes of interest included overall success of cardioversion with restoration of sinus rhythm, 1st shock success, 2nd shock success, mean shock energy required for successful cardioversion, mean number of shocks required for successful cardioversion, success of cardioversion at high energy (> 150 J) and success of cardioversion at low energy (< 150 J). Mantel-Haenszel risk ratios (RR) with 95% confidence intervals were calculated using random-effects model. RESULTS A total of 14 RCTs comprising 2445 patients were included. There was no statistically significant difference between two cardioversion approaches in the overall success of cardioversion (RR 1.02; 95% CI [0.97-1.06]; p = 0.43), first shock success (RR 1.14; 95% CI [0.99-1.32]), second shock success (RR 1.08; 95% CI [0.94-1.23]), mean shock energy required (mean difference 6.49; 95% CI [-17.33-30.31], success at high energy > 150 J (RR 1.02; 95% CI [0.92-1.14] and success at low energy < 150 J (RR 1.09; 95% CI [0.97-1.22]). CONCLUSIONS This meta-analysis of RCTs shows no significant difference in the success of cardioversion between antero-lateral vs. antero-posterior electrode position for cardioversion of AF. Large well-conducted and adequately powered randomized clinical trials are needed to definitively address this question.
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Affiliation(s)
- Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Sana Imran
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Miloni Parmar
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Awais Bajwa
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Derek Truong
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Siddharth Agarwal
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Asad Ghani
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Shari Clifton
- Robert M Bird Health Sciences Library, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jessica Reese
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, Oklahoma City, OK, USA
| | - Muhammad Shahzeb Khan
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, CA, USA
| | | | - Chittur Sivaram
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Warren M Jackman
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sunny Po
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sana M Al-Khatib
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
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Vinter N, Holst-Hansen MZB, Johnsen SP, Lip GYH, Frost L, Trinquart L. Electrical energy by electrode placement for cardioversion of atrial fibrillation: a systematic review and meta-analysis. Open Heart 2023; 10:e002456. [PMID: 37945283 PMCID: PMC10649887 DOI: 10.1136/openhrt-2023-002456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE Electrode patch position may not be critical for success when cardioverting atrial fibrillation (AF), but the relevance of applied electrical energy is unclarified. Our objective was to perform a meta-analysis of randomised trials to examine the dose-response relation between energy level and cardioversion success by electrode position in elective cardioversion. METHODS We searched PubMed, Embase, The Cochrane Library, Google Scholar and Scopus Citations. Inclusion criteria were randomised controlled trials using biphasic shock waves and self-adhesive patches, and publication date from 2000 to 2023. We used random-effects dose-response models to meta-analyse the relation between energy level and cardioversion success by anterolateral and anteroposterior position. Random-effects models estimated pooled risk ratios (RR) for cardioversion success after the first and the final shocks between the two electrode positions. RESULTS We included five randomised controlled trials (N=1078). After the first low-energy shock, the electrode position was not significantly associated with the likelihood of successful cardioversion (pooled RR anterolateral vs anteroposterior placement 1.28, 95% CI 0.93 to 1.76, with considerable heterogeneity). After a high-energy final shock, there was no evidence of an association between the electrode position and the cumulative chance of cardioversion success (pooled RR anterolateral vs anteroposterior 1.05, 95% CI 0.97 to 1.14). Regardless of electrode position, cardioversion success was significantly less likely with shock energy levels < 200J compared with 200J. CONCLUSION Evidence from contemporary randomised trials suggests that higher level of electrical energy is associated with higher conversion rate when cardioverting AF with a biphasic shockwave. Positioning of electrodes can be based on convenience.
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Affiliation(s)
- Nicklas Vinter
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Lars Frost
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ludovic Trinquart
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
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Motawea KR, Mostafa MR, Aboelenein M, Magdi M, Fathy H, Swed S, Belal MM, Awad DM, Elhalag RH, Talat NE, Rozan SS, Nashwan AJ, Battikh N, Sawaf B, Albuni MK, Battikh E, Mohamed GM, Farwati A, Aiash H. Anteriolateral versus anterior-posterior electrodes in external cardioversion of atrial fibrillation: A systematic review and meta-analysis of clinical trials. Clin Cardiol 2023; 46:359-375. [PMID: 36756856 PMCID: PMC10106664 DOI: 10.1002/clc.23987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 01/15/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023] Open
Abstract
The efficacy of anteriolateral versus anterior-posterior electrode positions in the success of atrial fibrillation's (AF) electrical cardioversion is unclear. Our aim is to perform a meta-analysis to compare the success rate of both electrode positions. PUBMED, WOS, OVID, and SCOPUS were searched. Inclusion criteria were clinical trials that compared anterior-lateral with anterior-posterior electrodes in external cardioversion of AF. After the full-text screening, 11 trials were included in the analysis. The total number of patients included in the study is 1845. The pooled analysis showed a statistically significant association between anterior-lateral electrode and increased cardioversion rate of AF (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.02-1.92, p = .04). Subgroup analysis revealed a statistically significant association between the anterior-lateral electrode and increased cardioversion rate of AF in subgroups of less than five shocks, patients with 60 years old or more and patients with left atrial (LA) diameter >45 mm (OR = 1.72, 95% CI = 1.17-2.54, p = .006), (OR = 1.73, 95% CI = 1.18-2.54, p = .005), and (OR = 1.86, 95% CI = 1.04-3.34, p = .04), respectively. Anteriolateral electrode is more effective than anterior-posterior electrode in external cardioversion of AF, particularly in patients who have received less than 5 shocks, are 60 years old or older and have a LA diameter greater than 45 mm.
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Affiliation(s)
- Karam R Motawea
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mostafa R Mostafa
- Department of Medicine, Rochester Regional Health/Unity Hospital, Rochester, New York, USA
| | | | - Mohamed Magdi
- Department of Medicine, Rochester Regional Health/Unity Hospital, Rochester, New York, USA
| | - Hager Fathy
- Faculty of Medicine, Minia University, Minya, Egypt
| | - Sarya Swed
- Faculty of Medicine, Aleppo University, Aleppo, Syria
| | - Mohamed M Belal
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Dina M Awad
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Rowan H Elhalag
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Nesreen E Talat
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Samah S Rozan
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Naim Battikh
- John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
| | - Bisher Sawaf
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Mhd K Albuni
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Elias Battikh
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Gihan M Mohamed
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Amr Farwati
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Hani Aiash
- Cardiovascular Perfusion Department, Upstate Medical University, Syracuse, New York, USA
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Darrat Y, Leung S, Elayi L, Parrott K, Ogunbayo G, Kotter J, Sorrell V, Gupta V, Anaya P, Morales G, Catanzarro J, Delisle B, Elayi CS. A stepwise external cardioversion protocol for atrial fibrillation to maximize acute success rate. Europace 2023; 25:828-834. [PMID: 36748366 PMCID: PMC10062296 DOI: 10.1093/europace/euad009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/29/2022] [Indexed: 02/08/2023] Open
Abstract
AIMS Cardioversion is a very commonly performed procedure for persistent atrial fibrillation (AF). However, there is no well-defined protocol to address failed external electrical direct current cardioversion. The aim of the study is to test the efficacy of a pre-defined stepwise cardioversion protocol for patients with persistent AF of ≤12 months. Success was the achievement of sinus rhythm. METHODS AND RESULTS The study population included patients with persistent AF of ≤12 months duration requiring rhythm management. Patients were offered cardioversion using a pre-defined stepwise protocol using different electrode placement locations, applying compression at end of expiration, and higher energy delivered simultaneously through two defibrillators. : A total of 414 patients were included in the study, of which 362 (87.4%) required a single successful cardioversion. The remaining 52 (12.5%) patients required additional cardioversion attempts using the stepwise cardioversion protocol with an overall success rate of 99.3%. Two simultaneous defibrillators were required in 14 patients (3.4%). Patients with multiple cardioversions (13.5%) experienced more local skin irritation and pain compared with patients with single cardioversion (13.5% vs. 3.5%, P = 0.004). The predictor for the need for multiple cardioversion attempts is high body mass index, while high transthoracic impedance is associated with failed cardioversion. No major complications were observed during the study. CONCLUSION The stepwise cardioversion protocol has a high success rate of >99% and can be safely performed in outpatient or inpatient settings.
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Affiliation(s)
- Yousef Darrat
- Cardiac Electrophysiology Department, Saint Joseph Hospital, 1401 Harrodsburg Road, Lexington, KY 40504, USA
| | - Steve Leung
- Department of Internal Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Liliane Elayi
- Cardiac Electrophysiology Department, Saint Joseph Hospital, 1401 Harrodsburg Road, Lexington, KY 40504, USA
| | - Kevin Parrott
- Cardiac Electrophysiology Department, Baptist Health, Louisville, KY, USA
| | - Gbolahan Ogunbayo
- Department of Internal Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - John Kotter
- Department of Internal Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Vincent Sorrell
- Department of Internal Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Vedant Gupta
- Department of Internal Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Paul Anaya
- Department of Internal Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Gustavo Morales
- Cardiac Electrophysiology Department, Grandview Medical Center, Birmingham, AL, USA
| | - John Catanzarro
- Department of Internal Medicine, The University of Florida, Jacksonville, FL, USA
| | - Brian Delisle
- Department of Internal Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Claude S Elayi
- Cardiac Electrophysiology Department, Saint Joseph Hospital, 1401 Harrodsburg Road, Lexington, KY 40504, USA
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Nguyen ST, Belley-Côté EP, Ibrahim O, Um KJ, Lengyel A, Adli T, Qiu Y, Wong M, Sibilio S, Benz AP, Wolf A, Whitlock NJ, Gabriel Acosta J, Healey JS, Baranchuk A, McIntyre WF. Techniques improving electrical cardioversion success for patients with atrial fibrillation: a systematic review and meta-analysis. Europace 2022; 25:318-330. [PMID: 36503970 PMCID: PMC9935008 DOI: 10.1093/europace/euac199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS Electrical cardioversion is commonly used to restore sinus rhythm in patients with atrial fibrillation (AF), but procedural technique and clinical success vary. We sought to identify techniques associated with electrical cardioversion success for AF patients. METHODS AND RESULTS We searched MEDLINE, EMBASE, CENTRAL, and the grey literature from inception to October 2022. We abstracted data on initial and cumulative cardioversion success. We pooled data using random-effects models. From 15 207 citations, we identified 45 randomized trials and 16 observational studies. In randomized trials, biphasic when compared with monophasic waveforms resulted in higher rates of initial [16 trials, risk ratio (RR) 1.71, 95% CI 1.29-2.28] and cumulative success (18 trials, RR 1.10, 95% CI 1.04-1.16). Fixed, high-energy (≥200 J) shocks when compared with escalating energy resulted in a higher rate of initial success (four trials, RR 1.62, 95% CI 1.33-1.98). Manual pressure when compared with no pressure resulted in higher rates of initial (two trials, RR 2.19, 95% CI 1.21-3.95) and cumulative success (two trials, RR 1.19, 95% CI 1.06-1.34). Cardioversion success did not differ significantly for other interventions, including: antero-apical/lateral vs. antero-posterior positioned pads (initial: 11 trials, RR 1.16, 95% CI 0.97-1.39; cumulative: 14 trials, RR 1.01, 95% CI 0.96-1.06); rectilinear/pulsed biphasic vs. biphasic truncated exponential waveform (initial: four trials, RR 1.11, 95% CI 0.91-1.34; cumulative: four trials, RR 0.98, 95% CI 0.89-1.08) and cathodal vs. anodal configuration (cumulative: two trials, RR 0.99, 95% CI 0.92-1.07). CONCLUSIONS Biphasic waveforms, high-energy shocks, and manual pressure increase the success of electrical cardioversion for AF. Other interventions, especially pad positioning, require further study.
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Affiliation(s)
- Stephanie T Nguyen
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Emilie P Belley-Côté
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,Population Health Research Institute, McMaster University, Hamilton, Ontario L8L 2X2, Canada
| | - Omar Ibrahim
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Kevin J Um
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Alexandra Lengyel
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Taranah Adli
- Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 5C1, Canada
| | - Yuan Qiu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,University of Ottawa, Ottawa, Ontario K1N 6N5, Canada
| | - Michael Wong
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Serena Sibilio
- Istituto Clinico Sant’Ambrogio, Università di Milano, Milano 20157, Italy
| | - Alexander P Benz
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Mainz 55131, Germany
| | - Alex Wolf
- University of Limerick School of Medicine, Limerick V94 T9PX, Ireland
| | - Nicola J Whitlock
- Bishop Tonnos Catholic Secondary School, Ancaster, Ontario L9G 5E3, Canada
| | - Juan Gabriel Acosta
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Jeff S Healey
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,Population Health Research Institute, McMaster University, Hamilton, Ontario L8L 2X2, Canada
| | - Adrian Baranchuk
- Queen’s University School of Medicine, Queen’s University, Kingston, Ontario K7L 3L4, Canada
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Virk SA, Rubenis I, Brieger D, Raju H. Anteroposterior Versus Anterolateral Electrode Position for Direct Current Cardioversion of Atrial Fibrillation: A Meta-Analysis of Randomised Controlled Trials. Heart Lung Circ 2022; 31:1640-1648. [PMID: 36163316 DOI: 10.1016/j.hlc.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/06/2022] [Accepted: 08/18/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Data regarding optimal electrode positioning for direct current cardioversion (DCCV) of atrial fibrillation (AF) has been inconsistent. This meta-analysis was conducted to systematically compare the efficacy of anteroposterior (AP) versus anterolateral (AL) electrode placement for DCCV of AF. METHODS Electronic databases were searched for randomised controlled trials (RCTs) comparing AP versus AL electrode positioning in patients undergoing DCCV for AF. Primary endpoints were first-shock success and overall DCCV success. Subgroup analysis was performed by defibrillator waveform (monophasic versus biphasic). Meta-regression analyses were performed to assess for significant moderators. RESULTS Twelve (12) RCTs, including a total of 2,046 patients, met inclusion criteria. Neither first-shock success (relative risk [RR] 0.92; 95% CI 0.79-1.07; p=0.28) nor overall DCCV success (RR 1.01; 95% CI 0.96-1.05; p=0.78) were significantly different with AP versus AL electrode positioning. The mean number of shocks (mean difference [MD] 0.3, 95% CI -0.4 to 0.9), energy level of first successful shock (MD 3 joules; 95% CI -20 to 27) and cumulative energy delivered (MD 39 joules; 95% CI -168 to 246) were similar in AP versus AL arms. In subgroup analysis of six RCTs using biphasic defibrillators, improvement in first-shock success (RR 0.85; 95% CI 0.69-1.03; p=0.10) and overall DCCV success (RR 0.97; 95% CI 0.93-1.01; p=0.09) with AL electrode positioning did not reach statistical significance. Meta-regression analyses identified older age, higher body mass index, and longer AF duration as significant moderators favouring AL electrode positioning. CONCLUSIONS Pooled analysis of randomised data overall does not show a significant difference in efficacy between AP versus AL electrode positioning. Meta-regression and subgroup analyses suggest that, in contemporary practice with use of biphasic defibrillators, there may be a subset of AF patients in whom AL electrode positioning improves efficacy of DCCV.
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Affiliation(s)
- Sohaib A Virk
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Imants Rubenis
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Hariharan Raju
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
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Eid M, Abu Jazar D, Medhekar A, Khalife W, Javaid A, Ahsan C, Shabarek N, Saad M, Rao M, Ong K, Jneid H, Elbadawi A. Anterior-Posterior versus anterior-lateral electrodes position for electrical cardioversion of atrial fibrillation: A meta-analysis of randomized controlled trials. IJC HEART & VASCULATURE 2022; 43:101129. [PMID: 36304256 PMCID: PMC9593304 DOI: 10.1016/j.ijcha.2022.101129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/15/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Abstract
Background The optimal electrodes position for elective direct current (DC) cardioversion of patients with atrial fibrillation (AF) remains uncertain. Methods An electronic search of MEDLINE, EMBASE and COCHRANE databases was performed through March 2022 for randomized trials that examined the outcomes of anterior-posterior (AP) versus anterior-lateral (AL) electrodes position during cardioversion of (AF). The main outcome was the success rate of cardioversion. Data were pooled using random effects model. Results The final analysis included 10 RCTs with a total of 1677 patients. There was no difference in the rate of successful cardioversion between the AP versus AL groups (86.6 vs 87.9 %; RR 1.00; 95 % Confidence Interval (CI) 0.95 to 1.06). Subgroup analysis by the shock waveform showed no significant interaction between monophasic and biphasic waveforms (Pintercation = 0.23). meta-regression analyses showed no effect modification of primary outcome according to body mass index (p = 0.15), left atrial diameter (p = 0.64), valvular heart disease (p = 0.34), lone AF (p = 0.58), or the duration of AF (p = 0.70). There was no significant difference between the AP and AL electrode position groups in successful cardioversion at low energy (RR 0.94; 95 % CI 0.74 to 1.19), the number of the delivered shocks (standardized mean difference [SMD] −0.03; 95 % CI −0.32 to 0.26) or the mean energy of the delivered shocks (SMD −0.11 and 95 % CI −0.30 to 0.07). There was lower transthoracic impedance with AP versus AL electrode position (SMD −0.28; 95 %CI −0.47 to −0.10). Conclusion Meta-analysis of randomized data showed no difference between AP and AL electrode positions in the success rate of DC cardioversion of AF. Either AP or AL electrode positions should be acceptable approaches for elective DC cardioversion of patients with AF.
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Affiliation(s)
- Mennaallah Eid
- Department of Internal Medicine, Lincoln Medical Center, New York, NY, United States
| | - Deaa Abu Jazar
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Ankit Medhekar
- Section of Cardiology, Baylor College of Medicine, Houston, TX, United States
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, United States
| | - Awad Javaid
- Department of Cardiology-University of Nevada, Las Vegas-Kirk Kirkorian School of Medicine, USA
| | - Chowdhury Ahsan
- Department of Cardiology-University of Nevada, Las Vegas-Kirk Kirkorian School of Medicine, USA
| | - Nehad Shabarek
- Department of Internal Medicine, Lincoln Medical Center, New York, NY, United States
| | - Marwan Saad
- Division of interventional structural Heart Research, Lifespan Cardiovascular Institute Interventional Cardiology and Structural Heart Disease, Rhode Island, NY, United States
| | - Mohan Rao
- Division of Cardiology, Rochester General Hospital, Rochester, NY, United States
| | - Kenneth Ong
- Division of Cardiology, Lincoln Medical Center, New York, NY, United States
| | - Hani Jneid
- Section of Cardiology, Baylor College of Medicine, Houston, TX, United States
| | - Ayman Elbadawi
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States,Corresponding author at: Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9047, United States.
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10
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A Systematic Review of the Transthoracic Impedance during Cardiac Defibrillation. SENSORS 2022; 22:s22072808. [PMID: 35408422 PMCID: PMC9003563 DOI: 10.3390/s22072808] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 02/01/2023]
Abstract
For cardiac defibrillator testing and design purposes, the range and limits of the human TTI is of high interest. Potential influencing factors regarding the electronic configurations, the electrode/tissue interface and patient characteristics were identified and analyzed. A literature survey based on 71 selected articles was used to review and assess human TTI and the influencing factors found. The human TTI extended from 12 to 212 Ω in the literature selected. Excluding outliers and pediatric measurements, the mean TTI recordings ranged from 51 to 112 Ω with an average TTI of 76.7 Ω under normal distribution. The wide range of human impedance can be attributed to 12 different influencing factors, including shock waveforms and protocols, coupling devices, electrode size and pressure, electrode position, patient age, gender, body dimensions, respiration and lung volume, blood hemoglobin saturation and different pathologies. The coupling device, electrode size and electrode pressure have the greatest influence on TTI.
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11
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Schmidt AS, Lauridsen KG, Møller DS, Christensen PD, Dodt KK, Rickers H, Løfgren B, Albertsen AE. Anterior-Lateral Versus Anterior-Posterior Electrode Position for Cardioverting Atrial Fibrillation. Circulation 2021; 144:1995-2003. [PMID: 34814700 DOI: 10.1161/circulationaha.121.056301] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Smaller randomized studies have reported conflicting results regarding the optimal electrode position for cardioverting atrial fibrillation. However, anterior-posterior electrode positioning is widely used as a standard and believed to be superior to anterior-lateral electrode positioning. Therefore, we aimed to compare anterior-lateral and anterior-posterior electrode positioning for cardioverting atrial fibrillation in a multicenter randomized trial. METHODS In this multicenter, investigator-initiated, open-label trial, we randomly assigned patients with atrial fibrillation scheduled for elective cardioversion to either anterior-lateral or anterior-posterior electrode positioning. The primary outcome was the proportion of patients in sinus rhythm after the first shock. The secondary outcome was the proportion of patients in sinus rhythm after up to 4 shocks escalating to maximum energy. Safety outcomes were any cases of arrhythmia during or after cardioversion, skin redness, and patient-reported periprocedural pain. RESULTS We randomized 468 patients. The primary outcome occurred in 126 patients (54%) assigned to the anterior-lateral electrode position and in 77 patients (33%) assigned to the anterior-posterior electrode position (risk difference, 22 percentage points [95% CI, 13-30]; P<0.001). The number of patients in sinus rhythm after the final cardioversion shock was 216 (93%) assigned to anterior-lateral electrode positioning and 200 (85%) assigned to anterior-posterior electrode positioning (risk difference, 7 percentage points [95% CI, 2-12]). There were no significant differences between groups in any safety outcomes. CONCLUSIONS Anterior-lateral electrode positioning was more effective than anterior-posterior electrode positioning for biphasic cardioversion of atrial fibrillation. There were no significant differences in any safety outcome. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03817372.
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Affiliation(s)
- Anders Sjørslev Schmidt
- Department of Internal Medicine, Randers Regional Hospital, Denmark (A.S.S., K.G.L., H.R., B.L.).,Research Center for Emergency Medicine, Aarhus University Hospital, Denmark (A.S.S., K.G.L., B.L.)
| | - Kasper Glerup Lauridsen
- Department of Internal Medicine, Randers Regional Hospital, Denmark (A.S.S., K.G.L., H.R., B.L.).,Research Center for Emergency Medicine, Aarhus University Hospital, Denmark (A.S.S., K.G.L., B.L.)
| | | | - Per Dahl Christensen
- Department of Cardiology, Viborg Regional Hospital, Denmark (D.S.M., P.D.C., A.E.A.)
| | - Karen Kaae Dodt
- Department of Internal Medicine, Horsens Regional Hospital, Denmark (K.K.D.)
| | - Hans Rickers
- Department of Internal Medicine, Randers Regional Hospital, Denmark (A.S.S., K.G.L., H.R., B.L.)
| | - Bo Løfgren
- Department of Internal Medicine, Randers Regional Hospital, Denmark (A.S.S., K.G.L., H.R., B.L.).,Research Center for Emergency Medicine, Aarhus University Hospital, Denmark (A.S.S., K.G.L., B.L.).,Department of Clinical Medicine, Aarhus University (B.L.)
| | - Andi Eie Albertsen
- Department of Cardiology, Viborg Regional Hospital, Denmark (D.S.M., P.D.C., A.E.A.)
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12
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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13
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Anantharaman V, Wan PW, Tay SY, Manning PG, Lim SH, Chua SJT, Mohan T, Rabind AC, Vidya S, Hao Y. Role of peak current in conversion of patients with ventricular fibrillation. Singapore Med J 2017; 58:432-437. [PMID: 28741007 DOI: 10.11622/smedj.2017070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Peak currents are the final arbiter of defibrillation in patients with ventricular fibrillation (VF). However, biphasic defibrillators continue to use energy in joules for electrical conversion in hopes that their impedance compensation properties will address transthoracic impedance (TTI), which must be overcome when a fixed amount of energy is delivered. However, optimal peak currents for conversion of VF remain unclear. We aimed to determine the role of peak current and optimal peak levels for conversion in collapsed VF patients. METHODS Adult, non-pregnant patients presenting with non-traumatic VF were included in the study. All defibrillations that occurred were included. Impedance values during defibrillation were used to calculate peak current values. The endpoint was return of spontaneous circulation (ROSC). RESULTS Of the 197 patients analysed, 105 had ROSC. Characteristics of patients with and without ROSC were comparable. Short duration of collapse < 10 minutes correlated positively with ROSC. Generally, patients with average or high TTI converted at lower peak currents. 25% of patients with high TTI converted at 13.3 ± 2.3 A, 22.7% with average TTI at 18.2 ± 2.5 A and 18.6% with low TTI at 27.0 ± 4.7 A (p = 0.729). Highest peak current conversions were at < 15 A and 15-20 A. Of the 44 patients who achieved first-shock ROSC, 33 (75.0%) received < 20 A peak current vs. > 20 A for the remaining 11 (25%) patients (p = 0.002). CONCLUSION For best effect, priming biphasic defibrillators to deliver specific peak currents should be considered.
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Affiliation(s)
| | - Paul Weng Wan
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Seow Yian Tay
- Emergency Department, Tan Tock Seng Hospital, Singapore
| | | | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Tiru Mohan
- Accident and Emergency Department, Changi General Hospital, Singapore
| | | | - Sudarshan Vidya
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Ying Hao
- Health Services Research Unit, Singapore General Hospital, Singapore
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14
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Kirkland S, Stiell I, AlShawabkeh T, Campbell S, Dickinson G, Rowe BH. The efficacy of pad placement for electrical cardioversion of atrial fibrillation/flutter: a systematic review. Acad Emerg Med 2014; 21:717-26. [PMID: 25117151 DOI: 10.1111/acem.12407] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 02/24/2014] [Accepted: 02/25/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Electrical cardioversion is commonly used to treat patients with atrial fibrillation and atrial flutter to restore normal sinus rhythm. There has been considerable debate as to whether the electrode placement affects the efficacy of electrical cardioversion. The objective of this study was to examine the effectiveness of anteroposterior (A-P) versus anterolateral (A-L) electrode placement to restore normal sinus rhythm. METHODS A search of eight electronic databases, including Medline, EMBASE, CINAHL, and Cochrane was completed. Grey literature (hand-searching, Google, and SCOPUS) searching was also conducted. Studies were included if they were controlled clinical trials comparing the effectiveness of A-P versus A-L pad placement to restore normal sinus rhythm in adult patients with atrial fibrillation and flutter. Two independent reviewers judged study relevance, inclusion, and quality (e.g., risk of bias). Individual and pooled statistics were calculated as relative risks (RRs) with 95% confidence intervals (CIs) using a random-effects model, and heterogeneity (I(2) ) was reported. RESULTS From 788 citations, 13 studies were included; seven involved monophasic, five involved biphasic, and one analyzed both waveform devices. The included studies tended to report cumulative success rates to restoring normal sinus rhythm after one to five sequential shocks of increasing energy; the number of shocks and energy used differed among studies. The risk of bias of the studies was "unclear." After the first shock, pad placement was not associated with an increased likelihood of restoring normal sinus rhythm (RR = 0.88; 95% CI = 0.73 to 1.06); however, heterogeneity was high (I(2) = 63%). Subgroup comparisons revealed that the A-L position was more effective (RR = 0.77; 95% CI = 0.59 to 1.00) at restoring normal sinus rhythm when using biphasic shocks (comparison p = 0.04). Overall, the pooled results failed to identify a difference between A-P and A-L pad placement in restoring normal sinus rhythm at any time (RR = 1.00; 95% CI = 0.95 to 1.05); however, heterogeneity was high (I(2) = 61%). No significant subgroup differences were found. Side effects were reported in only three studies. CONCLUSIONS The published literature is restricted to persistent atrial fibrillation and atrial flutter, pad placement varied, and energy levels used were lower than currently recommended; however, the accumulated evidence suggests that electrical pad placement is not a critically important factor in successful cardioversion in atrial fibrillation and flutter (AF/AFL). A trial is urgently needed in recent-onset atrial fibrillation and atrial flutter patients using biphasic devices and high energy levels to resolve the debate.
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Affiliation(s)
- Scott Kirkland
- Department of Emergency Medicine; University of Alberta; Edmonton Alberta Canada
| | - Ian Stiell
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Tariq AlShawabkeh
- Department of Emergency Medicine; University of Alberta; Edmonton Alberta Canada
| | - Sandy Campbell
- J. W. Scott Health Sciences Library; University of Alberta; Edmonton Alberta Canada
| | - Garth Dickinson
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Brian H. Rowe
- Department of Emergency Medicine; University of Alberta; Edmonton Alberta Canada
- School of Public Health; University of Alberta; Edmonton Alberta Canada
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15
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Zhang B, Li X, Shen D, Zhen Y, Tao A, Zhang G. Anterior-posterior versus anterior-lateral electrode position for external electrical cardioversion of atrial fibrillation: A meta-analysis of randomized controlled trials. Arch Cardiovasc Dis 2014; 107:280-90. [DOI: 10.1016/j.acvd.2014.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 03/29/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
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16
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Comparison of defibrillation efficacy between two pads placements in a pediatric porcine model of cardiac arrest. Resuscitation 2012; 83:755-9. [DOI: 10.1016/j.resuscitation.2011.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 12/05/2011] [Accepted: 12/08/2011] [Indexed: 11/21/2022]
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Falcão LFDR, Ferez D, do Amaral JLG. Update on cardiopulmonary resuscitation guidelines of interest to anesthesiologists. Rev Bras Anestesiol 2012; 61:624-40, 341-50. [PMID: 21920213 DOI: 10.1016/s0034-7094(11)70074-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 01/31/2011] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The new cardiopulmonary resuscitation (CPR) guidelines emphasize the importance of high-quality chest compressions and modify some routines. The objective of this report was to review the main changes in resuscitation practiced by anesthesiologists. CONTENTS The emphasis on high-quality chest compressions with adequate rate and depth allowing full recoil of the chest and with minimal interruptions is highlighted in this update. One should not take more than ten seconds checking the pulse before starting CPR. The universal relationship of 30:2 is maintained, modifying its order, initiating with chest compressions, followed by airways and breathing (C-A-B instead of A-B-C). The procedure "look, listen, and feel whether the patient is breathing" was removed from the algorithm, and the use of cricoid pressure during ventilations is not recommended any more. The rate of chest compressions was changed for at least one hundred per minute instead of approximately one hundred per minute, and its depth in adults was changed to 5 cm instead of the prior recommendation of 4 to 5 cm. The single shock is maintained, and it should be of 120 to 200 J when it is biphasic; and 360 J when it is monophasic. In advanced cardiac life support, the use of capnography and capnometry to confirm intubation and monitoring the quality of CPR is a formal recommendation. Atropine is no longer recommended for routine use in the treatment of pulseless electrical activity or asystole. CONCLUSIONS Updating the phases of the new CPR guidelines is important, and continuous learning is recommended. This will improve the quality of resuscitation and survival of patients in cardiac arrest.
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Affiliation(s)
- Luiz Fernando dos Reis Falcão
- Pain and Intensive Care Medicine Discipline of the Universidade Federal de São Paulo-Escola Paulista de Medicina, Brazil.
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Abstract
Recognition and appropriate treatment of ventricular fibrillation or pulseless ventricular tachycardia is an essential skill for healthcare providers. Appropriate defibrillation can improve survival and benefit patient outcome. Similarly, increased public access to automatic electronic defibrillators has been shown to improve out-of-hospital survival for cardiac arrest. When combined with high-quality cardiopulmonary resuscitation, electrical therapies are an important aspect of resuscitation in the patient with cardiac arrest. This article focuses on the use of electrical therapies, including defibrillation, cardiac pacing, and automated external defibrillators, in cardiac arrest.
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Link MS, Atkins DL, Passman RS, Halperin HR, Samson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. Part 6: Electrical Therapies. Circulation 2010; 122:S706-19. [DOI: 10.1161/circulationaha.110.970954] [Citation(s) in RCA: 223] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Muñoz-Martínez T, Castañeda-Saiz A, Vinuesa-Lozano C, Aretxabala-Kortajarena N, Dudagoitia-Otaolea J, Iribarren-Diarasarri S, Ruiz-Zorrilla J, Hernández-López M, Castillo-Arenal C. Estudio aleatorizado sobre la posición de electrodos en la cardioversión eléctrica electiva de la fibrilación auricular. Med Intensiva 2010; 34:225-30. [DOI: 10.1016/j.medin.2009.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 10/14/2009] [Accepted: 10/20/2009] [Indexed: 10/20/2022]
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Vogiatzis IA, Sachpekidis V, Vogiatzis IM, Kambitsi E, Karamitsos T, Samanidis D, Tsagaris V, Simeonidou O. External cardioversion of atrial fibrillation: The role of electrode position on cardioversion success. Int J Cardiol 2009; 137:e8-10. [DOI: 10.1016/j.ijcard.2008.05.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Revised: 03/11/2008] [Accepted: 05/10/2008] [Indexed: 10/21/2022]
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Zimetbaum P, Falk RH. Atrial Fibrillation. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Muñoz Martínez T, Martínez Alútiz S, Vinuesa Lozano C, Poveda Hernández Y, Dudagoitia Otaolea JL, Iribarren Diarasarri S, Hernández López M. [Comparison of two electrode positions in electrical cardioversion of atrial fibrillation]. Med Intensiva 2006; 30:137-42. [PMID: 16750075 DOI: 10.1016/s0210-5691(06)74493-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study aims to compare effectiveness of electrical cardioversion (ECV) in patients with chronic atrial fibrillation (AF) according to the electrode positions: anteroapical (A-A) or anteroposterior (A-P). That which restores the sinus rhythm (SR) using the least energy is considered superior. DESIGN Observational study comparing two consecutive series of patients. SCOPE. Intensive Care Unit (ICU) of second level hospital. PATIENTS AND METHODS Out-patients in AF referred to the ICU for biphasic ECV. The first series began with position A-A and the second one with A-P, administering up to 3 shocks (150-200-200J), changing to the alternative position if SR was not achieved and administering 2 more shocks of 200J. Age, gender, weight, baseline heart disease, ejection fraction, left atrial size, AF time, baseline vital signs, antiarrhythmic medication, reversion to SR, number of shocks, energy used and side effects were analyzed and compared between both series. RESULTS. A total of 50 patients were treated in each group. The baseline characteristics were similar except for a greater percentage of women in group A-A. The anteroapical electrode position achieved SR with significantly fewer numbers of shocks and less energy, more frequently achieving reversion on the first shock. CONCLUSIONS We found greater effectiveness in the electrical cardioversion of the AF with the electrodes in the anteroapical position, that we recommend as first choice. If it is not effective, the A-P position should be attempted.
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Affiliation(s)
- T Muñoz Martínez
- Unidad de Cuidados Intensivos, Hospital Txagorritxu, Vitoria-Gasteiz, España.
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Siaplaouras S, Buob A, Rötter C, Böhm M, Jung J. Randomized comparison of anterolateral versus anteroposterior electrode position for biphasic external cardioversion of atrial fibrillation. Am Heart J 2005; 150:150-2. [PMID: 16084162 DOI: 10.1016/j.ahj.2004.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2004] [Accepted: 08/09/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND In biphasic external cardioversion (CV) of atrial fibrillation (AF), the influence of different electrode positions on efficacy and incidence of early recurrent atrial fibrillation is not known. This study compared anteroposterior (AP) vs anterolateral (AL) electrode positioning. METHODS Consecutive patients referred for CV of persistent AF were randomized either to an AP or an AL electrode position. Biphasic external CV was performed with standardized electrode positions and rising energy delivery. RESULTS Both groups (N = 123, mean age 66 years, 71% male, 83% with structural cardiovascular disease or hypertension) did not differ concerning age, sex, body mass index, chronic antiarrhythmic therapy, duration of AF, left ventricular ejection fraction, and left atrial diameter. Cumulative success rates were comparable (AP 94.9% vs AL 95.2%, P = ns). First-shock efficacy did not differ (AP 78.3% vs AL 74.6%, P = ns). Early recurrent atrial fibrillation (AF relapse < 1 minute after successful CV) occurred in 8.1% (AP 11.6% vs AL 4.8%, P = ns). Mean number of shocks was 1.3 per patient with the AP configuration and 1.4 per patient with the AL configuration (P = ns). Mean cumulative energy delivery was also comparable (AP 171 WS vs AL 198 WS, P = ns). CONCLUSIONS Both electrode positions are similar in biphasic external CV of AF with regard to acute success and early recurrent atrial fibrillation. Also, the number of shocks needed and energy delivery are comparable with both electrode configurations.
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Affiliation(s)
- Stephanos Siaplaouras
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische, Intensivmedizin), Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.
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Walsh SJ, McCarty D, McClelland AJJ, Owens CG, Trouton TG, Harbinson MT, O'Mullan S, McAllister A, McClements BM, Stevenson M, Dalzell GWN, Adgey AAJ. Impedance compensated biphasic waveforms for transthoracic cardioversion of atrial fibrillation: a multi-centre comparison of antero-apical and antero-posterior pad positions. Eur Heart J 2005; 26:1298-302. [PMID: 15824079 DOI: 10.1093/eurheartj/ehi196] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS To compare the success rate for transthoracic direct current cardioversion (DCC) of atrial fibrillation (AF) with antero-posterior (AP) and antero-apical (AA) electrode positions using an impedance compensated biphasic (ICB) waveform. METHODS AND RESULTS Three-hundred and seven patients [mean age 66 (SD+/-13), 195 male] with AF were recruited in three centres. Patients were randomized to an AA (n=150) or AP (n=144) pad position. Thirteen patients with implanted pacemakers were defaulted to the AP pad position. Cardioversion was performed using an ICB waveform with a 70, 100, 150, and 200 J energy selection protocol. If the fourth shock was unsuccessful, the pads were crossed over to the alternative position for a final 200 J shock. Shock 1 was successful in 54/150 (36%) AA and 45/144 (31%) AP patients, whereas success was achieved by shock 2 in 99/150 (66%) AA and 74/144 (51%) AP, by shock 3 in 123/150 (82%) AA and 109/144 (76%) AP, and by shock 4 in 143/150 (95%) AA and 127/144 (88%) AP and after cross-over in 144/150 (96%) AA and 135/144 (94%) AP. Overall success rate was higher than expected at 95%. Pad position was not associated significantly with success. There was a trend towards an improved outcome with the AA configuration (P=0.05). CONCLUSION The influence of pad position for DCC of AF may be less pertinent with ICB waveforms than with monophasic waveforms.
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Affiliation(s)
- Simon J Walsh
- Regional Medical Cardiology Centre, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK
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