Single or dual cardioversion in patients with obesity and AF?

Obese patients undergoing electrical cardioversion for atrial fibrillation (AF) appeared to benefit more from dual direct current (DC) than from single DC cardioversion, without an increased risk for complications.

“By 2030, an estimated 1 out of 4 adults will have a BMI ≥35 kg/m² and 6–16 million people in the USA will have AF,” outlined Dr Joshua Aymond (Ochsner Health, LA, USA) [1–3]. “These 2 conditions are strongly linked to one another.” Electrical cardioversion is the treatment of choice, but failure to restore sinus rhythm is seen in 20–35% of patients with obesity and <10% of patients without obesity [4]. However, higher shock energy may lead to a higher success rate in patients with obesity [5].

The current multicentre, randomised, patient-blinded study compared single DC cardioversion (with an energy of 200 J) with dual DC cardioversion (with an energy of 400 J) in patients with obesity and AF (n=200) [1]. The primary outcome was the restoration of sinus rhythm, regardless of duration, immediately following cardioversion.

The failure rate was 14% in the single DC cardioversion arm compared with 2% in the dual DC cardioversion arm (P=0.002). In addition, a multivariable analysis showed that the OR of failure was 12.6, disfavouring the single DC cardioversion arm. “Of the 14 patients that had failed single cardioversion, 12 succeeded on the first subsequent dual cardioversion,” said Dr Aymond. Finally, there were no differences in post-procedure chest discomfort between the study groups and no procedure-related adverse events.

Dr Jose Joglar (UT Southwestern Medical Center, TX, USA), a discussant of the trial, concluded that, although some unanswered questions remain, the results of the current trial suggest that cardiologists should be more liberal with the use of high energies for DC cardioversion and that an initial energy of 400 J has its place in clinical practice.

1. 
   
   1. Aymond JD, et al. Efficacy and safety of dual direct current cardioversion versus single direct current cardioversion as an initial treatment strategy in obese patients with atrial fibrillation. LB05, AHA Scientific Sessions 2023, 11–13 November, Philadelphia, USA.
   2. Ward ZJ, et al. N Engl J Med 2019;381(25):2440–2450.
   3. Myasaka Y, et al. Circulation. 2006;114(2):119–125.
   4. Gardner MW, et al. J Cardiovasc Electrophysiol. 2019;30(9):1636–1643.
   5. Glover BM, et al. Heart. 2008;94(7):884–887.

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Posted on 29 January 2024