Evaluation of a novel cardioversion intervention for atrial fibrillation: the Ottawa AF cardioversion protocol

F Daniel Ramirez; Mouhannad M Sadek; Isabelle Boileau; Mark Cleland; Pablo B Nery; Girish M Nair; Calum J Redpath; Martin S Green; Darryl R Davis; Karen Charron; Joshua Henne; Timothy Zakutney; Rob S B Beanlands; Benjamin Hibbert; George A Wells; David H Birnie

doi:10.1093/europace/euy285

Evaluation of a novel cardioversion intervention for atrial fibrillation: the Ottawa AF cardioversion protocol

Europace. 2019 May 1;21(5):708-715. doi: 10.1093/europace/euy285.

Authors

F Daniel Ramirez^{1

2}, Mouhannad M Sadek¹, Isabelle Boileau¹, Mark Cleland³, Pablo B Nery¹, Girish M Nair¹, Calum J Redpath¹, Martin S Green¹, Darryl R Davis^{1

4}, Karen Charron¹, Joshua Henne³, Timothy Zakutney³, Rob S B Beanlands¹, Benjamin Hibbert^{1

4}, George A Wells^{2

5}, David H Birnie¹

Affiliations

¹ Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada.
² School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
³ Biomedical Engineering, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
⁴ Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada.
⁵ Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Abstract

Aims: Electrical cardioversion is commonly performed to restore sinus rhythm in patients with atrial fibrillation (AF), but it is unsuccessful in 10-12% of attempts. We sought to evaluate the effectiveness and safety of a novel cardioversion protocol for this arrhythmia.

Methods and results: Consecutive elective cardioversion attempts for AF between October 2012 and July 2017 at a tertiary cardiovascular centre before (Phase I) and after (Phase II) implementing the Ottawa AF cardioversion protocol (OAFCP) as an institutional initiative in July 2015 were evaluated. The primary outcome was cardioversion success, defined as ≥2 consecutive sinus beats or atrial-paced beats in patients with implanted cardiac devices. Secondary outcomes were first shock success, sustained success (sinus or atrial-paced rhythm on 12-lead electrocardiogram prior to discharge from hospital), and procedural complications. Cardioversion was successful in 459/500 (91.8%) in Phase I compared with 386/389 (99.2%) in Phase II (P < 0.001). This improvement persisted after adjusting for age, body mass index, amiodarone use, and transthoracic impedance using modified Poisson regression [adjusted relative risk 1.08, 95% confidence interval (CI) 1.05-1.11; P < 0.001] and when analysed as an interrupted time series (change in level +9.5%, 95% CI 6.8-12.1%; P < 0.001). The OAFCP was also associated with greater first shock success (88.4% vs. 79.2%; P < 0.001) and sustained success (91.6% vs 84.7%; P=0.002). No serious complications occurred.

Conclusion: Implementing the OAFCP was associated with a 7.4% absolute increase in cardioversion success and increases in first shock and sustained success without serious procedural complications. Its use could safely improve cardioversion success in patients with AF.

Clinical trial number: www.clinicaltrials.gov ID: NCT02192957.

Keywords: Atrial fibrillation; Cardioversion; Defibrillation; Protocol; Quality improvement.

Publication types

Clinical Trial

MeSH terms

Atrial Fibrillation* / diagnosis
Atrial Fibrillation* / therapy
Clinical Protocols / standards*
Electric Countershock* / adverse effects
Electric Countershock* / methods
Electrocardiography / methods
Female
Humans
Male
Middle Aged
Outcome and Process Assessment, Health Care
Quality Improvement
Treatment Outcome

Associated data

ClinicalTrials.gov/NCT02192957