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Meta-Analysis
. 2023 Feb 16;25(2):318-330.
doi: 10.1093/europace/euac199.

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

Stephanie T Nguyen  1   2 , Emilie P Belley-Côté  2   3 , Omar Ibrahim  2 , Kevin J Um  2 , Alexandra Lengyel  1 , Taranah Adli  4 , Yuan Qiu  1   5 , Michael Wong  1 , Serena Sibilio  6 , Alexander P Benz  7 , Alex Wolf  8 , Nicola J Whitlock  9 , Juan Gabriel Acosta  2 , Jeff S Healey  2   3 , Adrian Baranchuk  10 , William F McIntyre  2   3
Affiliations
Meta-Analysis

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

Stephanie T Nguyen et al. Europace. .

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.

Keywords: Atrial fibrillation; Cardioversion techniques; Electrical cardioversion; Non-pharmacological interventions; Sinus rhythm restoration; Systematic review.

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Conflict of interest statement

Conflict of interest: None declared.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Forest plots for RCTs comparing biphasic and monophasic waveforms. (A) Initial cardioversion success. (B) Cumulative cardioversion success.
Figure 2
Figure 2
Forest plots of RCTs comparing fixed, high energy and low-dose, escalating energy. (A) Initial cardioversion success. (B) Cumulative cardioversion success.
Figure 3
Figure 3
Forest plots for RCTs comparing antero-apical/lateral and antero-posterior pad placement. (A) Initial cardioversion success. (B) Cumulative cardioversion success.
Figure 4
Figure 4
Forest plots for RCTs comparing manual pressure and no manual pressure. (A) Initial cardioversion success. (B) Cumulative cardioversion success.
See this image and copyright information in PMC

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