Best Evidence Topics
  • Send this BET as an Email
  • Make a Comment on this BET

Paddle position in emergency cardioversion of atrial fibrillation

Three Part Question

In [a patient with new onset AF who needs urgent electrical cardioversion] is [antero-posterior better than antero-lateral paddle position] at [reverting the patient to sinus rhythm]?

Clinical Scenario

A 60 year old man presents to the emergency department with a history of sudden onset palpitations. This is associated with some mild chest discomfort and breathlessness. On examination he is in atrial fibrillation at a rate of 180, and has a BP of 95/60. He looks pale and sweaty. You feel he needs urgent electrical cardioversion and wonder whether the paddle position used will affect your success rate.

Search Strategy

Medline 1966-09/04 using the OVID interface and The Cochrane Library, Issue 3, 2004 via the NeLH.
Medline: ([exp atrial fibrillation OR] AND [exp electric countershock OR electrode OR electrical OR DC]) LIMIT to human, English language AND adults.
Cochrane: [paddle] next [position]

Search Outcome

Altogether 954 papers were found of which 5 were relevant to the question. No additional papers were found in the Cochrane Library.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Mathew TP et al,
90 patients Elective Antero-Lateral (AL) vs. Antero-Posterior (AP) 100J then 200J, 300J, 360JProspective, randomisedCardioversion success rate38/45 success for AL vs. 33/45 for AP p=0.42No power Randomisation method not explicit Elective patients
Mean (SD) energy used223 (96.1) J for AL vs. 232 (110) J for AP
Mean (SD) thoracic impedance on 1st shock77.5 (18.4) Ohms AL vs. 73.7 (18.7) Ohms AP p=0.34
Alp NJ et al,
59 patients with persistent AF AP vs. AL (360 J)RCT cross-overCardioversion success rate on 1st 360J DC shockWith first 360J AL more successful 18/30 vs.10/29 for AP (p=0.048)Small numbers Elective Patients with persistent AF
Cardioversion 2nd 360J shock4/19 for AL vs. 5/12 for AP p=0.22
Botto GL et al,
301 patients with stable AF AL vs. AP 3J/kg then 4J/kg then 4J/kg in alternative positionProspective randomised controlled trialSuccess rate at initial 3J/Kg shock87/151 success for AL vs. 100/150 for APNo power calculation Randomisation method not explicit All elective with chronic AF
Cumulative success rate after 1st 4J/Kg shock114/151 for AL vs. 131/150 for AP (p=0.013)
Cumulative success after 2nd 4J/Kg shock140/150 for AL vs. 140/150 for AP p=NS
Kirchhof P et al,
108 patients with persistent AF Elective cardioversion (50-360J) AP vs. ALRCT cross-over (if no response in initial paddle position at 360J)Cardioversion success rate in initial paddle positions50/52 for AP vs. 44/56 for AL p=0.009Elective patients with persistent AF
Cardioversion if initial position failed8/12 cardioverted when crossed from AL to AP. No success in those AP to AL (2 patients)
Chen CJ & Guo GB,
70 patients with persistent AF (>1month). AL (31 patients) vs. AP (39 patients) Step up protocol 100, 150, 200, 300, 360 joulesRandomised controlled trialCardioversion success at 100JAP vs. AL 23% vs.19.4% p=NSSmall, low powered study Only looks at those with persistent AF in an elective setting (excluded those with new onset AF, 1 month) No randomisation details
Cumulative Cardioversion success at 150JAP vs. AL 41% vs. 45.2% p=NS
Cumulative Cardioversion success at 200JAP vs. AL 66.7% vs. 74.2% p=NS


AF is a common problem encountered in the emergency department. These papers shows that some good quality research has been done on cardioversion but not in the emergency setting. The 5 best papers show conflicting results regarding the positioning of paddles in elective cardioversion, the most recent showing no difference between the 2 positions. In our clinical scenario the AP position may be difficult to achieve in such an unwell, shocked patient.

Clinical Bottom Line

There is little evidence to suggest that paddle position significantly influences the success of cardioversion emergency department patients with AF.


  1. Mathew TP, Moore A, McIntyre M, et al. Randomised comparison of electrode positions for cardioversion of atrial fibrillation. Heart 1999;81(6):576-579.
  2. Alp NJ, Rahman S, Bell JA, et al. Randomised comparison of antero-lateral versus antero-posterior paddle positions for DC cardioversion of persistent atrial fibrillation. Int J Cardiol 2000;75(2-3):211-216.
  3. Botto GL, Politi A, Bonini W, et al. External cardioversion of atrial fibrillation: Role of paddle position on technical efficacy and energy requirements. Heart 1999;82(6):726-730.
  4. Kirchhof P, Eckardt L, Loh P, et al. Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: A randomised trial. Lancet 2002;360(9342):1275-1279.
  5. Chen CJ, Guo GB. External cardioversion in patients with persistent atrial fibrillation: a reappraisal of the effects of electrode pad position and transthoracic impedance on cardioversion success. Jpn Heart J 2003;44(6):921-32.