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Effect of pad placement on successful cardioversion of atrial fibrillation to normal sinus rhythm

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 reviewFirst-shock successNo significant different with AP versus AL electrode positioningFindings 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 successNo significant different with AP versus AL electrode positioning
Mean number of shocksNo significant different with AP versus AL electrode positioning
Energy level of first successful shockNo significant different with AP versus AL electrode positioning
Cumulative energy deliveredNo 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 reviewSuccessful cardioversion with first low energy shockNo significant difference in electrode positioningRelatively 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 shockNo significant difference in electrode positioning


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.


  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