Background: Electric cardioversion (ECV) is a common procedure to restore a sinus rhythm (SR) from an abnormal cardiac pulse. It is widely used as elective procedure to treat atrial fibrillation (AF) or flutter without signs of haemodynamic impairment, while its use in emergency is indicated in all the ventricular or supraventricular tachyarrhythmias with signs of severe haemodynamic impairment or cardiogenic shock. In our Internal Medicine Department (IMD), AF represents the fifth DRG in order of frequency. For this reason, we currently follow patients affected by AF waiting for an ECV with well-defined, evidence-based protocols. However, despite optimal medical therapy, we still frequently observe a failure to maintain SR in a high percentage of patients. For this reason, we retrospectively analyzed 121 patients admitted to our IMD for elective ECV, analyzing SR stability at 30 days after DC shock as our main outcome. Aims: To evaluate retrospectively an association between the number of shocks and the SR stability at 30 days after a successful ECV procedure. To our knowledge, there are no studies that enlightened the relationship between the number of DC shocks required to restore SR at the first electric cardioversion and SR maintenance at 30 days. Methods: We enrolled 121 consecutive patients admitted in our ED in the year 2010–2011 for an AF episode. We excluded 9 patients who underwent to ECV (all with SR restoration) within 48 h from the event. We excluded 52 patients who underwent to ECV for an AF relapse. 60 patients were suitable for analysis and were treated with the same pharmacologic protocol including 4 weeks of therapy with oral anticoagulants, a class III antiarrhythmic, an angiotensin-receptor blocker (irbesartan) and statins. After 4 weeks, patients underwent to ECV with standard protocol (first shock: 150J, second shock: 200J, third shock: 200J). We evaluated age, sex and comorbidities (cardiopathy, hypertension, diabetes mellitus, cerebrovascular or vascular pathology), drug therapy, the number of shocks required to restore SR and SR maintenance at 30 days. Statistical analysis, accounting for sex, age, therapies and comorbidities, was performed with a multinomial logistic regression model with SPSS 13.0 for Windows systems. Results: SR remained stable at 30 days in 48 patients; 12 patients had an AF relapse at 30 days. Adjusting for age, sex and comorbidities, we found that the number of shocks given during the ECV procedure was independently correlated with maintenance of SR at 30 days: subjects achieving SR restoration after the first shock had an OR of 14.083 (95 %IC: 3.708–53.496, p\0.05) of SR maintenance at 30 days in respect to patients who achieved SR after 2 or more shocks (Figure 1). Discussion: AF is the most common malignant arrhythmia observed in an IMD. Its mortality and morbidity is mainly related to internistic pathologies, such as cardioembolic stroke. In a recent work, our group observed how internistic comorbidities (hypertension, diabetes mellitus, chronic heart failure and stroke, coronaric and peripheral atherosclerotic pathology), age and sex, synthesized in the CHA2DS2- VASc variable, can predict the success of ECV at 24 h, probably indicating an electrical and mechanical remodeling of the atrium. This current work adds another piece to the puzzle of clinical prediction of ECV success in AF, enlightening the concept that refractoriness to DC shock could represent itself a marker of atrial electrical/ mechanical remodeling and warn the clinician on the high likelihood of short-term treatment failure in this subset of patients. Larger cohorts and multi-centric studies are required to validate this observation.
Relationship between stability of sinus rhythm and number of DC shock in a series of patients with AF undergoing to electrical cardioversion
L. Falsetti
Writing – Original Draft Preparation
;
2012
Abstract
Background: Electric cardioversion (ECV) is a common procedure to restore a sinus rhythm (SR) from an abnormal cardiac pulse. It is widely used as elective procedure to treat atrial fibrillation (AF) or flutter without signs of haemodynamic impairment, while its use in emergency is indicated in all the ventricular or supraventricular tachyarrhythmias with signs of severe haemodynamic impairment or cardiogenic shock. In our Internal Medicine Department (IMD), AF represents the fifth DRG in order of frequency. For this reason, we currently follow patients affected by AF waiting for an ECV with well-defined, evidence-based protocols. However, despite optimal medical therapy, we still frequently observe a failure to maintain SR in a high percentage of patients. For this reason, we retrospectively analyzed 121 patients admitted to our IMD for elective ECV, analyzing SR stability at 30 days after DC shock as our main outcome. Aims: To evaluate retrospectively an association between the number of shocks and the SR stability at 30 days after a successful ECV procedure. To our knowledge, there are no studies that enlightened the relationship between the number of DC shocks required to restore SR at the first electric cardioversion and SR maintenance at 30 days. Methods: We enrolled 121 consecutive patients admitted in our ED in the year 2010–2011 for an AF episode. We excluded 9 patients who underwent to ECV (all with SR restoration) within 48 h from the event. We excluded 52 patients who underwent to ECV for an AF relapse. 60 patients were suitable for analysis and were treated with the same pharmacologic protocol including 4 weeks of therapy with oral anticoagulants, a class III antiarrhythmic, an angiotensin-receptor blocker (irbesartan) and statins. After 4 weeks, patients underwent to ECV with standard protocol (first shock: 150J, second shock: 200J, third shock: 200J). We evaluated age, sex and comorbidities (cardiopathy, hypertension, diabetes mellitus, cerebrovascular or vascular pathology), drug therapy, the number of shocks required to restore SR and SR maintenance at 30 days. Statistical analysis, accounting for sex, age, therapies and comorbidities, was performed with a multinomial logistic regression model with SPSS 13.0 for Windows systems. Results: SR remained stable at 30 days in 48 patients; 12 patients had an AF relapse at 30 days. Adjusting for age, sex and comorbidities, we found that the number of shocks given during the ECV procedure was independently correlated with maintenance of SR at 30 days: subjects achieving SR restoration after the first shock had an OR of 14.083 (95 %IC: 3.708–53.496, p\0.05) of SR maintenance at 30 days in respect to patients who achieved SR after 2 or more shocks (Figure 1). Discussion: AF is the most common malignant arrhythmia observed in an IMD. Its mortality and morbidity is mainly related to internistic pathologies, such as cardioembolic stroke. In a recent work, our group observed how internistic comorbidities (hypertension, diabetes mellitus, chronic heart failure and stroke, coronaric and peripheral atherosclerotic pathology), age and sex, synthesized in the CHA2DS2- VASc variable, can predict the success of ECV at 24 h, probably indicating an electrical and mechanical remodeling of the atrium. This current work adds another piece to the puzzle of clinical prediction of ECV success in AF, enlightening the concept that refractoriness to DC shock could represent itself a marker of atrial electrical/ mechanical remodeling and warn the clinician on the high likelihood of short-term treatment failure in this subset of patients. Larger cohorts and multi-centric studies are required to validate this observation.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
