(Circulation. 2000;101:1282.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Transthoracic Cardioversion of Atrial Fibrillation
Comparison of Rectilinear Biphasic Versus Damped Sine Wave Monophasic Shocks
From The New York Hospital-Cornell Medical Center, New York, NY (S.M., K.M.S., S.M.M., D.J.S., M.A.S., B.B.L.); Zoll Medical Corporation, Burlington, Mass (S.A.); University of Pittsburgh Medical Center, Pittsburgh, Pa (D.S., D.C.); and Cleveland Clinic Foundation, Cleveland, Ohio (P.J.T.).
Correspondence to Bruce B. Lerman, MD, Division of Cardiology, The New York Hospital-Cornell Medical Center, 525 East 68th Street, Starr 4, New York, NY 10021. E-mail blerman{at}mail.med.cornell.edu
Background—Clinical studies have shown that biphasic shocks are more effective than monophasic shocks for ventricular defibrillation. The purpose of this study was to compare the efficacy of a rectilinear biphasic waveform with a standard damped sine wave monophasic waveform for the transthoracic cardioversion of atrial fibrillation.
Methods and Results—In this prospective, randomized, multicenter
trial, patients undergoing transthoracic cardioversion of
atrial fibrillation were randomized to receive either damped sine wave
monophasic or rectilinear biphasic shocks. Patients randomized to the
monophasic protocol (n=77) received sequential shocks of 100, 200, 300,
and 360 J. Patients randomized to the biphasic protocol (n=88) received
sequential shocks of 70, 120, 150, and 170 J. First-shock efficacy with
the 70-J biphasic waveform (60 of 88 patients, 68%) was significantly
greater than that with the 100-J monophasic waveform (16 of 77
patients, 21%, P<0.0001), and it was achieved with
50% less delivered current (11±1 versus 22±4 A,
P<0.0001). Similarly, the cumulative efficacy with the
biphasic waveform (83 of 88 patients, 94%) was significantly greater
than that with the monophasic waveform (61 of 77 patients, 79%;
P=0.005). The following 3 variables were
independently associated with successful cardioversion: use of a
biphasic waveform (relative risk, 4.2; 95% confidence intervals, 1.3
to 13.9; P=0.02), transthoracic impedance
(relative risk, 0.64 per 10-
increase in impedance; 95% confidence
intervals, 0.46 to 0.90; P=0.005), and duration of
atrial fibrillation (relative risk, 0.97 per 30 days of atrial
fibrillation; 95% confidence intervals, 0.96 to 0.99;
P=0.02).
Conclusions—For transthoracic cardioversion of atrial fibrillation, rectilinear biphasic shocks have greater efficacy (and require less energy) than damped sine wave monophasic shocks.
Key Words: cardioversion • atrial fibrillation • shock
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|
|
|
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|
|
|
|
|
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|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
 |
|
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|
|
|
|
|
|
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|
|
|
|
 |
|
 Ph. Ricard, K. Yaici, J.P. Rinaldi, M. Bergonzi, and N. Saoudi Cardioversion of atrial fibrillation: how and when? Eur. Heart J. Suppl., September 1, 2003; 5(suppl_H): H40 - H44. [Abstract] [PDF]
|
|
|
|
 |
|
 S K S Lairikyengbam, M H Anderson, and A G Davies Present treatment options for atrial fibrillation Postgrad. Med. J., February 1, 2003; 79(928): 67 - 73. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
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|
|
|
|
|
|
R. L. Page, R. E. Kerber, J. K. Russell, T. Trouton, J. Waktare, D. Gallik, J. E. Olgin, P. Ricard, G. W. Dalzell, R. Reddy, et al. Biphasic versus monophasic shock waveform for conversion of atrial fibrillation: The results of an international randomized, double-blind multicenter trial J. Am. Coll. Cardiol., June 19, 2002; 39(12): 1956 - 1963. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. S. Aronow Management of the Older Person With Atrial Fibrillation J. Gerontol. A Biol. Sci. Med. Sci., June 1, 2002; 57(6): M352 - 363. [Abstract] [Full Text]
|
|
|
|
|
|
Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology Eur. Heart J., October 2, 2001; 22(20): 1852 - 1923. [PDF]
|
|
|
|
|
|
V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology J. Am. Coll. Cardiol., October 1, 2001; 38(4): 1266 - 1266. [Full Text] [PDF]
|
|
|
|
 |
|
 R. H. Falk Atrial Fibrillation N. Engl. J. Med., April 5, 2001; 344(14): 1067 - 1078. [Full Text] [PDF]
|
|
|
|
|
|
H. J. G. M. Crijns Internal cardioversion as a first-line method of cardioversion? Europace, January 1, 2001; 3(1): 2 - 3. [PDF]
|
|
|
|
 |
|
 Biphasic Better Than Monophasic Shock in AF? Journal Watch Emergency Medicine, June 1, 2000; 2000(601): 3 - 3. [Full Text]
|
|
|
|
 |
|
 No Shock That Biphasics Are Better for Cardioversion of AF Journal Watch Cardiology, May 5, 2000; 2000(505): 9 - 9. [Full Text]
|
|