The efficacy of pad placement for electrical cardioversion of atrial fibrillation: a systematic review

The efficacy of pad placement for electrical cardioversion of atrial fibrillation: a systematic review Scott Kirkland, MSc Emergency Medicine Research...
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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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