The efficacy of pad placement for electrical cardioversion of atrial fibrillation: a systematic review Scott Kirkland, MSc Emergency Medicine Research Group (EMeRG) Department of Emergency Medicine University of Alberta
Collaborators University of Alberta •
Tariq AlShawabkeh, MD
•
Sandy Campbell, MLS
•
Brian H. Rowe, MD, MSc
University of Ottawa • Garth Dickenson, MD • Ian Stiell, MD, MSc
Disclosure The research team does not have any affiliation with a commercial organization that may have a direct or indirect connection to the content of this presentation.
Introduction • Electrical cardioversion (EC) is commonly used to treat patients with atrial fibrillation and/or flutter (AFF) to restore normal sinus rhythm (NSR). • During EC, electrodes may placed in either the anterolateral (A-L) or antero-posterior (A-P) position. A-L
A-P
Introduction • Clinical practice guidelines for treating patients with AFF recommends EC should be administered using biphasic waveform devices, and that the A-P position might be more effective than the A-L position in restoring NSR. • There has been, however, considerable debate on whether pad placement impacts the efficacy of EC. • Currently, it is unknown whether pad placement plays a role in restoring NSR in patients during EC.
Objectives • To examine the efficacy of A-P versus A-L electrode placement to restore NSR in patients with AFF. • Examine the role of monophasic and biphasic devices on the effectiveness of A-P and A-L to restore NSR.
PICO-D Population • Adult patients with recent or persistent AFF in a primary, secondary, or tertiary care setting; Intervention and Control • A-L versus A-P placement of electrical pads/paddles using monophasic/biphasic devices; Outcome • Conversion to normal sinus rhythm; Design • Randomized control clinical trials or controlled clinical trials.
Methods To avoid publication bias • Searched eight electronic databases including Medline, EMBASE, Cochrane registry, SCOPUS, CINAHL, LILACS, IEEE explore, and Proquest Dissertations. • Grey literature search, including Google scholar, clinical trial registries, and bibliographies of included studies and reviews. • No limits set for year of publication or language.
Methods To avoid selection bias • Two independent reviewers identified potentially eligible studies via abstracts/titles. • Once identified, two reviewers independently assessed the eligibility of the studies based on the PICO-D. Risk of Bias (RoB) assessment • Assessed using the RoB assessment tool. Completed independently by two reviewers. Disagreements resolved and discussed with a third party.
Methods Data pooling • Individual and pooled statistics were calculated as relative risks (RR) with 95% confidence intervals (CI) using a random effects model. Heterogeneity • Tested using the I2 statistic with I2 values of 25, 50, and 75% representing low, moderate, and high degrees of heterogeneity, respectively
Search Diagram Potentially relevant citations from search (n = 1,084).
Duplicates (n = 296).
Papers retrieved for more detailed evaluation (n = 788).
Clearly Irrelevant studies (n = 763).
Papers retrieved for more detailed evaluation ( n= 25). Excluded studies: (n=12).
Reasons for exclusion: • 11 studies were not RCT/CCT’s • 1 study did not compare A-P to A-L pad placement
Relevant studies (n = 13). Studies included in the review (n = 13).
Risk of Bias assessment 3
Adequate sequence generation
10
Low risk of bias High risk of bias
13
Allocation concealment
Unclear Blinding of participants, personnel and outcome assessors
2
11 5
Incomplete outcome addressed
Free of selective reporting
1
2
10 13
Free of other bias
Overall risk of bias
8
4
9
0 1 2 3 4 5 6 7 8 9 10 11 12 13 Number of articles (#)
Included studies
Reference
Location
Alp 2000 Botto 2001 Brazdzionyte 2006 Chen 2003
United Kingdom Italy Lithuania Taiwan
Recent onset /Persistent afib/flutter Persistent Persistent Recent onset/Persistent Persistent
No. of Subjects
Waveform
Shock protocol
Crossover?
59 301 103
Monophasic Monophasic Biphasic
360 J 3 J/kg-4 J/kg 100-150- 200-300 J
1 360 J shock 1 4 J/kg shock none
70
Monophasic
none
Persistent
108
Monophasic
United Kingdom
Persistent
90
Monophasic
100-150-200-300360 J 50-100-200-300360 J 100-200-300-360 J
Kirchoff 2002 Mathew 1999 MunozMartinez 2010 Risius 2009
Germany
none
Spain
Persistent
91
Biphasic
150-200-200 J
2 200 J shocks
Germany
Recent onset/Persistent Persistent
96
Biphasic
1 200 J shock
123
Biphasic
50-75-100-150-200 J 120-150-200-200 J
Siaplaouras 2005
Germany
Stanaitiene 2008
Lithuania
Recent onset/Persistent
224
Monophasic & Biphasic
Tuinenburg 1997
Netherlands
Persistent
70
Vogiatzis 2008 Walsh 2005
Greece
Persistent
United Kingdom
Persistent
1 360 J shock
none
Monophasic
Mono 100-150200-300-360 J Biphasic 100-200300-360 J 100-200-360-360 J
none
none
62
Monophasic
200-300-360 J
none
294
Biphasic
70-100-150-200 J
1 200 J shock
Cardioversion success - First shock
Cardioversion success – overall success rate
Discussion • The accumulated evidence suggests that electrical pad placement is not a critically important factor in successful cardioversion of AFF; however, A-L placement for the initial shock appears to be more effective when using biphasic devices. • Other factors (e.g., chest impedance, duration of AFF, voltage) likely also play important roles in successful EC.
Limitations • Potential limitations include a small number trials (n = 13). • Potential publication bias. • No studies investigating recent onset or ED AFF. • Low quality studies using RofB assessment. • High variation in study protocols. • Inconsistent reporting of outcomes.
Acknowledgements •
Canadian Association of Emergency Physicians (CAEP) Research Consortium.
•
Department of Emergency Medicine University of Alberta.
•
Corresponding authors: Drs. Stephanos Siaplaouras, Tim Risius and Tomas Munoz.
•
Dr. Steil holds a Distinguished Professorship and University Health Research Chair from the University of Ottawa.
•
Dr. Rowe is supported as a Tier I Canada Research Chair in Evidence-based Emergency Medicine by CIHR (Ottawa, ON).
Thank You!
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