Cardioversion with maximum-fixed shocks confers better outcomes vs. low-escalating energy shocks

PARIS — Cardioversion with maximum-fixed energy shocks was more effective than low-escalating energy shocks for the treatment of patients with atrial fibrillation, according to a late-breaking science presentation at the European Society of Cardiology Congress.

Perspective from Sabine Ernst, MD, FESC

Anders Sjørslev Schmidt, MD, PhD candidate at Randers Regional Hospital in Denmark, and colleagues analyzed data from 276 patients with AF who were assigned to either low-escalating energy shocks (n = 147; mean age, 68 years; 74% men), which included shocks ranging from 125 J to 200 J, or maximum-fixed energy shocks (n = 129; mean age, 68 years; 70% men), which was delivered at 360 J.

The primary endpoint was sinus rhythm 1 minute after cardioversion. Safety endpoints including myocardial injury, cases of arrhythmia, patient-reported discomfort or pain and skin redness or burns were also assessed. Results from this study were also published in the European Heart Journal.

With regards to the primary endpoint, sinus rhythm was achieved 1 minute after cardioversion in 88% of patients in the maximum-fixed group and 66% of those in the low-escalating group (difference = 22%; 95% CI, 12-32; P < .001). Four hours after cardioversion, sinus rhythm was observed in 85% of patients assigned maximum-fixed energy shocks vs. 63% of those assigned low-escalating energy shocks (difference = 22%; 95% CI, 12-32; P < .001).

Cardioversion with maximum-fixed energy shocks was more effective than low-escalating energy shocks for the treatment of patients with atrial fibrillation, according to a late-breaking science presentation at the European Society of Cardiology Congress.

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The median number of shocks delivered in the maximum-fixed energy group was 1 compared with 2 in the low-escalating energy group. There was a marginal decrease in the median procedure duration with maximum-fixed energy compared with low-escalating energy (1.9 minutes vs. 2.2 minutes).

Arrhythmias occurred in 5% of each treatment group.

No changes in troponin levels were seen from before and after cardioversion in both groups.

“In fact, for a few patients included in the low-escalating group with a very high baseline troponin level, the troponin level dropped after cardioversion,” Schmidt said during the presentation.

There were no cases of skin burns as a result of cardioversion in both groups, and there were comparable rates for mild or no redness. Rates of patient-reported discomfort or pain were similar in both groups.

“We found no difference in any safety point,” Schmidt said during the presentation. – by Darlene Dobkowski

References:

Schmidt AS, et al. Late Breaking Science in Atrial Fibrillation 1. Presented at: European Society of Cardiology Congress; Aug. 31 to Sept. 4, 2019; Paris.

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Schmidt AS, et al. Eur Heart J. 2019;doi:10.1093/eurheartj/ehz585.

Disclosures: Schmidt reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Perspective

Sabine Ernst, MD, FESC

The results are not surprising and reflect common sense. In other words, high-energy shocks are better, require less attempts, resolves sinus rhythm with a higher percentage than 125 J, 150 J and 200 J escalating.

It was good that this trial was done in a randomized fashion because there was still a lot of debate about this. In my own hospital, there was a big debate about if low-escalating shocks should not be state of the art. I always found that counterintuitive, and I insisted for my patients that we do biphasic high-energy shocks because I see no point.

Some of the patient characteristics that you would need to know include those such as whether a more obese patient has a higher risk to fail with low-energy shocks. These are the kinds of things that need to be teased out as clinical guidance for patients to go and for clinicians to say, “OK, I will follow this advice.” We need to accept that as a message now. I hope this kind of trial will be recognized in the upcoming guidelines, advising the clinician of how to apply it.

You would be surprised to hear how many hospitals, even cardiac centers or tertiary centers, do not have high-energy defibrillators on their wards. You would think that it sounds so counterintuitive.

I salute the researcher for presenting this. He’s a PhD student, so this was amazing. It was well done, well delivered and a very good discussion. The science and the clinical outcome are important.

You could say the design of this trial that if the low-energy group failed all of the shocks, rather than sending the patient home and rescheduling the whole thing, say, “OK, you failed at the endpoint, but we’ll give you a 360 J shock to resolve it.” From that standpoint, I probably would have designed the study differently, but of course this is cleaner and the endpoint after 4 hours would have not been reached. That would have been the limitation, as you would have only judged it on 1 minute or after a certain waiting time.

I like the applicability very much. This is something you can take home and change in your own practice tomorrow.

Sabine Ernst, MD, FESC

Cardiac Electrophysiologist

Imperial College London

Consultant Cardiologist

Royal Brompton and Harefield NHS Foundation Trust, England

Disclosures: Ernst reports no relevant financial disclosures.

European Society of Cardiology

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Cardioversion with maximum-fixed shocks confers better outcomes vs. low-escalating energy shocks

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