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Three Part Question

[In adults with unstable atrial fibrillation and rapid ventricular response] is [anterior-posterior transcutaneous pad placement] as opposed to [anterior-lateral pad placement] have [improved first time successful conversion]?

Clinical Scenario

A 65-year-old man presents with shortness of breath, was subsequently found on electrocardiogram to have acute onset rapid ventricular response to his chronic atrial fibrillation with a ventricular rate of 160. The patient’s blood pressure was 72/42 mm Hg. Anteroposterior transcutaneous pads were placed on the patient’s chest placement for electrical cardioversion. You wonder if anterolateral pad placement might be more effective for converting atrial fibrillation.

Search Strategy

Medline 1966-06/24 using PubMed, Cochrane Library (2024), and Embase
[(electrodes/standards OR electrode placement OR pad placement) AND (atrial Fibrillation/therapy)] LIMIT to English language.

Search Outcome

16 total articles were found; two recent systematic reviews were identified as both relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Virk SA, et al. December 2022 Sydney, NSW, Australia	Meta-analyses of 12 RCTs (N=2046) comparing AP versus AL electrode positioning in patients undergoing cardioversion for AF.	Systematic review	First-shock success	No significant different with AP versus AL electrode positioning	Findings from these studies using monophasic defibrillators may not be applicable to contemporary clinical practice using biphasic defibrillators. There was variation between studies with regards to shock protocol used for DCCV, definition of success, clinical characteristics of participants and the approach to anti-arrhythmic drug therapy prior to DCCV.
			Overall DCCV success	No significant different with AP versus AL electrode positioning
			Mean number of shocks	No significant different with AP versus AL electrode positioning
			Energy level of first successful shock	No significant different with AP versus AL electrode positioning
			Cumulative energy delivered	No significant different with AP versus AL electrode positioning
Vinter N, et al. November 2023 Denmark, United Kingdom, USA	Meta-analysis of 5 RCTs (N=1078) that compared anterolateral versus anteroposterior electrode positioning in cardioversion of AF using biphasic shock.	Systematic review	Successful cardioversion with first low energy shock	No significant difference in electrode positioning	Relatively small studies with limited statistical power and precision. Considerable clinical diversity across studies resulting in large statistical heterogeneity. Studies were non-blinded, and outcome assessment was blinded in only one study.
			Successful cardioversion with final high energy shock	No significant difference in electrode positioning

Comment(s)

Several systematic reviews with meta-analyses of randomized controlled trials have shown no substantial differences between the two electrode positions. A higher level of electrical energy (200J possibly followed by shocks up to 360J) appears to be more important for effective electrical cardioversion than the electrode position.

Clinical Bottom Line

There is no evidence of an association between the electrode position and the cumulative chance of cardioversion success. Positioning of electrodes can be based on physician’s discretion.

References

1. Virk SA, Rubenis I, Brieger D, Raju H. Anteroposterior Versus Anterolateral Electrode Position for Direct Current Cardioversion of Atrial Fibrillation: A Meta-Analysis of Randomised Controlled Trials. Heart Lung Circ 2022 Dec;31(12):1640-1648
2. Vinter N, Holst-Hansen MZB, Johnsen SP, Lip GYH, Frost L, Trinquart L. Electrical energy by electrode placement for cardioversion of atrial fibrillation: a systematic review and meta-analysis Open Heart 2023 Nov;10(2):e002456