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Manual Chest PRESSURE During Direct Current Cardioversion for Atrial Fibrillation: A Randomized Control Trial
David Ferreira1, Philopatir Mikhail2, Joyce Lim3
1Cardiovascular Department, John Hunter Hospital, Newcastle, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, New South Wales, Australia; Hunter Medical Research Institute, Newcastle, New South Wales, Australia.
Insights
Applying chest pressure during direct current cardioversion for atrial fibrillation (AF) did not improve cardioversion success. This randomized trial found no significant difference in energy required or outcomes between groups, suggesting chest pressure is not routinely beneficial for AF cardioversion.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Direct current cardioversion is a common procedure for restoring sinus rhythm in patients with atrial fibrillation (AF).
- Chest pressure during cardioversion is hypothesized to enhance efficacy by reducing transthoracic impedance and improving energy delivery.
Purpose of the Study:
- To evaluate the efficacy and safety of applying upfront chest pressure during direct current cardioversion for atrial fibrillation (AF).
- To assess the impact of chest pressure on energy requirements and cardioversion success rates.
Main Methods:
- A multicenter, double-blinded, randomized clinical trial involving 311 patients undergoing cardioversion for AF.
- Patients received either standard cardioversion or cardioversion with concurrent chest pressure using an anterior-posterior pad configuration.
- Key outcomes included total joules, first shock success, transthoracic impedance, and cardioversion success at 30 minutes post-procedure.
Main Results:
- No significant difference was observed in the total joules required per patient encounter between the control and chest pressure groups (355.0 ± 301 J vs 413.8 ± 347 J; P = 0.19).
- First shock success, total shocks, average impedance, and overall cardioversion success rates were similar in both arms.
Conclusions:
- The routine application of chest pressure during direct current cardioversion for atrial fibrillation is not supported by these findings.
- The PRESSURE-AF trial indicates that chest pressure does not offer a significant benefit in improving cardioversion efficacy.
Background:
Direct current cardioversion is frequently used to return patients with atrial fibrillation (AF) to sinus rhythm. Chest pressure during cardioversion may improve the efficacy of cardioversion through decreasing transthoracic impedance and increasing cardiac energy delivery.
Objectives:
This study aimed to assess the efficacy and safety of upfront chest pressure during direct current cardioversion for AF with anterior-posterior pad positioning.
Methods:
This was a multicenter, investigator-initiated, double-blinded, randomized clinical trial. Recruitment occurred from 2021 to 2023. Follow-up was until hospital discharge. Recruitment occurred across 3 centers in New South Wales, Australia. Inclusion criteria were age ≥18 years, referred for cardioversion for AF, and anticoagulation for 3 weeks or transesophageal echocardiography excluding left atrial appendage thrombus. Exclusion criteria were other arrhythmias requiring cardioversion, such as atrial flutter and atrial tachycardia. The intervention arm received chest pressure during cardioversion from the first shock. The primary efficacy outcome was total joules required per patient encounter. Secondary efficacy outcomes included first shock success, transthoracic impedance, cardioversion success, and sinus rhythm at 30 minutes post cardioversion.
Results:
A total of 311 patients were randomized, 153 to control and 158 to intervention. There was no difference in total joules applied per encounter in the control arm vs intervention arm (355.0 ± 301 J vs 413.8 ± 347 J; P = 0.19). There was no difference in first shock success, total shocks provided, average impedance, and cardioversion success.
Conclusions:
This study does not support the routine application of chest pressure for direct current cardioversion in atrial fibrillation (PRESSURE-AF [Investigating the Efficacy of Chest Pressure for Direct Current Cardioversion in Atrial Fibrillation: A Randomized Controlled Trial]; ACTRN12620001028998).
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