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Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity
TAKE-HOME MESSAGE
- This prospective, multicenter, randomized clinical trial compared the effectiveness and safety of dual direct-current cardioversion (DCCV) using two sets of pads with those of traditional single 200-joule DCCV in patients with obesity (BMI, ≥35 kg/m2) and atrial fibrillation. Dual DCCV achieved a higher rate of cardioversion success (98%) than single DCCV (86%), with no incidence of post-procedure chest discomfort or cardiovascular complications.
- These findings suggest dual DCCV may offer a more effective cardioversion strategy for patients with obesity and atrial fibrillation, improving success rates without compromising patient safety or comfort in this growing patient population.
abstract
This abstract is available on the publisher's site.
Access this abstract nowIMPORTANCE
Atrial fibrillation and obesity are common, and both are increasing in prevalence. Obesity is associated with failure of cardioversion of atrial fibrillation using a standard single set of defibrillator pads, even at high output.
OBJECTIVE
To compare the efficacy and safety of dual direct-current cardioversion (DCCV) using 2 sets of pads, with each pair simultaneously delivering 200 J, with traditional single 200-J DCCV using 1 set of pads in patients with obesity and atrial fibrillation.
DESIGN, SETTING, AND PARTICIPANTS
This was a prospective, investigator-initiated, patient-blinded, randomized clinical trial spanning 3 years from August 2020 to 2023. As a multicenter trial, the setting included 3 sites in Louisiana. Eligibility criteria included body mass index (BMI) of 35 or higher (calculated as weight in kilograms divided by height in meters squared), age 18 years or older, and planned nonemergent electrical cardioversion for atrial fibrillation. Patients who met inclusion criteria were randomized 1:1. Exclusions occurred due to spontaneous cardioversion, instability, thrombus, or BMI below threshold.
INTERVENTIONS
Dual DCCV vs single DCCV.
MAIN OUTCOMES AND MEASURES
Return to sinus rhythm, regardless of duration, immediately after the first cardioversion attempt of atrial fibrillation, adverse cardiovascular events, and chest discomfort after the procedure.
RESULTS
Of 2079 sequential patients undergoing cardioversion, 276 met inclusion criteria and were approached for participation. Of these, 210 participants were randomized 1:1. After exclusions, 200 patients (median [IQR] age, 67.6 [60.1-72.4] years; 127 male [63.5%]) completed the study. The mean (SD) BMI was 41.2 (6.5). Cardioversion was successful more often with dual DCCV compared with single DCCV (97 of 99 patients [98%] vs 87 of 101 patients [86%]; P = .002). Dual cardioversion predicted success (odds ratio, 6.7; 95% CI, 3.3-13.6; P = .01). Patients in the single cardioversion cohort whose first attempt failed underwent dual cardioversion with all subsequent attempts (up to 3 total), all of which were successful: 12 of 14 after second cardioversion and 2 of 14 after third cardioversion. There was no difference in the rating of postprocedure chest discomfort (median in both groups = 0 of 10; P = .40). There were no cardiovascular complications.
CONCLUSIONS AND RELEVANCE
In patients with obesity (BMI ≥35) undergoing electrical cardioversion for atrial fibrillation, dual DCCV results in greater cardioversion success compared with single DCCV, without any increase in complications or patient discomfort.
Additional Info
Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity: A Randomized Clinical Trial
JAMA Cardiol 2024 Jul 01;9(7)641-648, JD Aymond, AM Sanchez, MR Castine, ML Bernard, S Khatib, AE Hiltbold, GM Polin, PA Rogers, PS Dominic, C Velasco-Gonzalez, DP MorinFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Obesity is a significant risk factor for atrial fibrillation (AF) and is associated with a higher burden of AF, faster progression from paroxysmal to persistent to permanent AF, and an increased risk of AF recurrence following AF ablation.1-4 These relationships are likely mediated through epicardial and abdominal fat, structural changes in the atria, and the relationship of obesity with various comorbidities also associated with AF (eg, hypertension and obstructive sleep apnea).3,4
The acute management of AF often includes external direct-current cardioversion (DCCV). In patients with obesity, AF is more resistant to electrical cardioversion, which may be related to greater interelectrode distance, higher transthoracic impedance, and larger atrial size.1,3-5 Cardioversion is usually performed using a single defibrillator connected to a single pair of electrodes. In cases where AF is refractory to single cardioversion, a “dual DCCV” is sometimes used, with some success. Until recently, only case reports and case series were published on the topic. The 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of AF briefly addresses the challenges of electrical cardioversion in patients with obesity and mentions that dual DCCV can be considered for patients with obesity who have failed DCCV. However, given the scarcity of clinical data, the guidelines make no formal recommendation on this approach.1
This prospective, multicenter, patient-blinded, randomized clinical trial by Aymond et al is the first to investigate dual DCCV as an initial cardioversion strategy in patients with obesity. Patients with obesity (BMI, ≥35 kg/m2) undergoing non-emergent electrical cardioversion for AF were randomized to single DCCV or dual DCCV. Of 200 patients (median [IQR] age, 67.6 [60.1–72.4] years; mean BMI, 41.2 ± 6.5 kg/m2; male, 63.5%), 99 who received dual DCCV had a significantly higher success rate (98% vs 86%; P = .002) and greater corrected odds of successful cardioversion (OR, 6.7; P = .01) than patients who received single DCCV. Per protocol, patients who failed single DCCV (n = 14) subsequently underwent dual cardioversion, achieving a cumulative cardioversion success rate of 100% after up to two dual DCCV shocks were delivered. There were no differences between the groups in self-reported post-procedure chest discomfort or adverse events.
Given the considerable failure rates of single DCCV in patients with obesity, dual DCCV should be considered as an initial strategy for cardioversion of AF in this population.
References