Atrial Fibrillation Clinical Trial
Official title:
The Efficiency and Safety of a High Energy Shock Protocol (360-360-360 J) Versus a Standard Escalating Energy Shock Protocol (125-150-200 J) in Cardioverting Atrial Fibrillation
Atrial fibrillation is the most common heart rhythm disorder. For patients suffering atrial
fibrillation direct current cardioversion is performed to reduce patients symptoms and
prevent disease progression. The optimal energy selection for biphasic cardioversion is
unknown.
We aim to investigate the efficiency and safety of a high energy shock protocol (360 J)
versus a standard escalating shock protocol (125-150-200 J) in cardioversion of atrial
fibrillation.
The optimal energy selection for biphasic direct current (DC) cardioversion of atrial
fibrillation is unknown. The energy delivered should be sufficient to achieve prompt
cardioversion but without the risk of inducing any potential injury e.g. skin burns,
myocardial stunning or post-cardioversion arrhythmias. The use of an escalating protocol,
with a low energy initial shock, has been considered conventional practice, originally to
avoid post cardioversion arrhythmias when using monophasic shocks.(1) This practice has been
directly transferred to biphasic cardioversion. The European Society of Cardiology 2016
guidelines (2) and the American Heart Association/American College of Cardiology 2014
guidelines on the management of atrial fibrillation (3) do not recommend any specific energy
settings, whereas the European Resuscitation Council 2010 guidelines for cardiopulmonary
resuscitation (4) recommend a starting energy level of 120-200 J with subsequent escalating
energy setting.
Previously, a non-escalating protocol (200 J) (5) has been found to have a significantly
higher first shock success resulting in fewer shock deliveries without compromising safety
compared with a low energy escalating shock protocol (100-150-200 J). Further, a study found
fewer arrhythmic complications with increasing energy suggesting an 'upper limit of
vulnerability'. It is well-established that biphasic shocks induce fewer post-shock
arrhythmias (6), skin burns (7) and shorter periods of myocardial stunning compared with
monophasic shocks.(8) Importantly, no correlation between increasing biphasic energy delivery
and any complications was found in these studies. Nonetheless, the efficiency and safety of a
high energy shock (360 J) biphasic protocol compared with a conventional low energy
escalating protocol is unknown. Accordingly, this study aims to compare the efficiency and
safety of a high energy protocol (360-360-360 J) versus a standard escalating protocol
(125-150-200 J). We hypothesise that a high energy cardioversion protocol is more effective
compared to standard escalating energy protocol, without compromising safety.
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