Non-pharmacological interventions to improve the success of electrical cardioversion in patients with atrial fibrillation

Abstract

Background: Electrical cardioversion (ECV) is a common management strategy for atrial fibrillation (AF). ECV contains multiple modifiable components, including pad size and placement, shock energy, and waveform phases. Guidance on optimal technique, however, is limited. A comprehensive review of interventions used to increase ECV success will guide ideal clinical practice and identify techniques that could be studied in future randomized controlled trials. Methods: This review will include RCTs randomized controlled trial and observational studies that compare acute cardioversion success between 2 or more non-pharmacological interventions in patients with AF undergoing ECV. We will search CENTRAL, MEDLINE and EMBASE from inception to present and will also include the grey literature as part of our search. We will assess the risk of bias for each study and summarize the extracted data in a narrative report with a table of findings included. Results: Based on a full search strategy developed for MEDLINE along with findings from the grey literature search, the non-pharmacological interventions are expected to include pad placement, shock energy, waveform phases, and manual pressure, among others. Conclusions: The objective of this scoping review is to identify and examine the evidence on non-pharmacological interventions to improve electrical cardioversion in patients with AF. Registered on Open Science Framework: https://osf.io/gdh27/

Letter by Ibrahim et al Regarding Article, “Anterior–Lateral Versus Anterior–Posterior Electrode Position for Cardioverting Atrial Fibrillation”

“…Our systematic review and meta-analysis of randomized trials also concluded that existing data are insufficient to ascertain optimal pad placement when using the modern standard of biphasic, maximal energy waveforms. 2 Only 1 trial compared anterior-posterior and anterior-lateral placement while using fixed-maximal energy with a biphasic waveform; it was a substudy of only 160 patients and was neither adequately powered nor specifically designed to address this question. 5 Although the trial by Schmidt et al 1 is rigorous and internally valid, it used an escalating energy protocol, which limits its external validity.…”

“…Our systematic review and meta-analysis of randomized trials regarding nonpharmacologic interventions to improve cardioversion success, 2 presented at the American Heart Association Scientific Sessions in 2021, found that fixed-maximal energy protocols were superior to escalating protocols for first shock success in converting atrial fibrillation to sinus rhythm (relative risk, 1.62 [95% CI, 1.33–1.98]). Minimizing the number of shocks required to convert atrial fibrillation to sinus rhythm is desirable, because it leads to shorter procedure duration and reduced requirements for sedation.…”

Techniques improving electrical cardioversion success for patients with atrial fibrillation: a systematic review and meta-analysis

“…We pre-registered the protocol with Open Science Framework (DOI:10.17605/OSF.IO/FTU57). 16 We list the differences between the registered and final protocol in see Supplementary material online , Appendix S1 .…”

“…We searched CENTRAL, MEDLINE, and EMBASE from inception to October 2022 and searched the grey literature. 16 An academic librarian reviewed the search strategies (see Supplementary material online , Appendix S2 ).…”