Manual Chest PRESSURE During Direct Current Cardioversion for Atrial Fibrillation

BACKGROUND Direct current cardioversion is frequently used to return patients with atrial fibrillation (AF) to sinus rhythm. Chest pressure during cardioversion may improve the efficacy of cardioversion through decreasing transthoracic impedance and increasing cardiac energy delivery. OBJECTIVES This study aimed to assess the efficacy and safety of upfront chest pressure during direct current cardioversion for AF with anterior-posterior pad positioning. METHODS This was a multicenter, investigator-initiated, double-blinded, randomized clinical trial. Recruitment occurred from 2021 to 2023. Follow-up was until hospital discharge. Recruitment occurred across 3 centers in New South Wales, Australia. Inclusion criteria were age >= 18 years, referred for cardioversion for AF, and anticoagulation for 3 weeks or transesophageal echocardiography excluding left atrial appendage thrombus. Exclusion criteria were other arrhythmias requiring cardioversion, such as atrial flutter and atrial tachycardia. The intervention arm received chest pressure during cardioversion from the first shock. The primary efficacy outcome was total joules required per patient encounter. Secondary efficacy outcomes included first shock success, transthoracic impedance, cardioversion success, and sinus rhythm at 30 minutes post cardioversion. RESULTS A total of 311 patients were randomized, 153 to control and 158 to intervention. There was no difference in total joules applied per encounter in the control arm vs intervention arm (355.0 +/- 301 J vs 413.8 +/- 347 J; P = 0.19). There was no difference in first shock success, total shocks provided, average impedance, and cardioversion success. CONCLUSIONS This study does not support the routine application of chest pressure for direct current cardioversion in atrial fibrillation (PRESSURE-AF [Investigating the Efficacy of Chest Pressure for Direct Current Cardioversion in Atrial Fibrillation.