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

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.

Electrical energy by electrode placement for cardioversion of atrial fibrillation: a systematic review and meta-analysis

“…Recently, a systematic review with meta-analyses by Nguyen et al examined cardioversion success, electrode position and energy level, respectively. 7 We aimed to examine the relationship between energy level and cumulative cardioversion success. In contrast, Nguyen et al aimed to compare the cumulative cardioversion success between high-energy shocks (minimum 200J) and escalating energy protocols.…”

“…3 Yet, more systematic reviews with meta-analyses of randomised controlled trials (RCTs) have recently examined the optimal electrode position for cardioverting AF, but the results are conflicting. [6][7][8][9][10][11] Lately, attention has…”

Letter regarding “Anteriolateral versus anterior–posterior electrodes in external cardioversion of atrial fibrillation: A systematic review and meta‐analysis of clinical trials”

“…In contrast to Motawea et al, we found that overall cardioversion success did not differ when comparing AL to AP-positioned pads (Risk ratio: 1.01, 95% CI: 0.96-1.06, p = .70). 2 Two principal issues drive the differences between our studies' results. The first issue relates to study selection.…”

“…In contrast to Motawea et al, we found that overall cardioversion success did not differ when comparing AL to AP‐positioned pads (Risk ratio: 1.01, 95% CI: 0.96–1.06, p = .70). 2 …”

Tratamiento de la fibrilación auricular en el servicio de urgencias: una revisión práctica de la literatura

“…En cuanto a la posición de los electrodos, se ha discutido y en algunas publicaciones sugieren beneficio de la posición anteroposterior (mejor que anteroapical) 25 ; sin embargo, otras publicaciones niegan dicho beneficio 37 o concluyen que el posicionamiento de las almohadillas requiere estudios adicionales 38 .…”