Manual Chest PRESSURE during Direct Current Cardioversion for Atrial Fibrillation: A Randomised Control Trial (PRESSURE-AF)

ABSTRACT 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. We aimed to assess the efficacy and safety of upfront chest pressure during direct current cardioversion for atrial fibrillation with anterior-posterior pad positioning. Design, Setting and Participants This was a multi-center, investigator-initiated, patient and analysis blinded, randomised clinical trial. Recruitment occurred from 2021 to 2023. Follow-up was until hospital discharge. Recruitment occurred across three centers in New South Wales, Australia. Inclusion criteria were age ≥18, referred for cardioversion for AF, and anticoagulation for three weeks or transoesophageal echocardiography excluding left atrial appendage thrombus. Exclusion criteria were other arrhythmias requiring cardioversion, such as atrial flutter and atrial tachycardia. Intervention and Outcomes 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 311 patients were randomised, 153 to control and 158 to intervention. There was no difference in total joules applied per encounter in the control arm versus intervention arm (356.4 ± 301 vs 413.8 ± 347, P=0.25). There was no difference in first shock success, total shocks provided, average impedance and cardioversion success. Conclusions and Relevance This study does not support the routine application of chest pressure for direct current cardioversion in atrial fibrillation. Reducing the complexity of cardioversion will improve the efficiency of the procedure for patients and healthcare systems. Funding None to disclose Trial Registration ACTRN12620001028998