Comparison of Efficacy of Monophasic vs Biphasic Shocks for Transthoracic Cardioversion of Atrial Fibrillation

This study compares the effectiveness of monophasic and biphasic shocks for transthoracic cardioversion of atrial fibrillation. The research questions focus on whether biphasic shocks are more effective than monophasic shocks. The study aims to determine which shock is more effective in treating this condition.

Comparison between efficacy of
monophasic vs biphasic shocks for
transthoracic cardioversion of atrial
fibrillation

Table of Contents
LIST OF FIGURE AND TABLES..................................................................................................1
LIST OF ABBREVIATIONS..........................................................................................................2
ACKNOWLEDGEMENT...............................................................................................................3
ABSTRACT.....................................................................................................................................4
Background.............................................................................................................................4
Methods..................................................................................................................................4
Results....................................................................................................................................4
Conclusion..............................................................................................................................4
INTRODUCTION...........................................................................................................................6
What is transthoracic cardioversion of atrial fibrillation?......................................................6
Why research is important on this topic.................................................................................6
Two type of cardioversion......................................................................................................7
Need of transthoracic cardioversion of atrial fibrillation.......................................................8
Aim.........................................................................................................................................9
Objective.................................................................................................................................9
Research questions.................................................................................................................9
Alternative Hypothesis...........................................................................................................9
Null hypothesis.......................................................................................................................9
METHODOLOGY........................................................................................................................10
Criteria for eligibility............................................................................................................10
Source of information...........................................................................................................14
PICO framework..................................................................................................................14
Screening of studies..............................................................................................................15
Quality assessment and data extraction................................................................................16
Heterogeneity.......................................................................................................................19
Statistics................................................................................................................................20
RESULTS......................................................................................................................................24
PRISMA flowchart...............................................................................................................24
Quality assessment...............................................................................................................28

Data extraction table.............................................................................................................28
DISCUSSION................................................................................................................................31
Risk of bias: ethics................................................................................................................31
Summary of finding..............................................................................................................32
Raw data...............................................................................................................................32
Similar studies......................................................................................................................33
Follow up period...................................................................................................................34
Method based on follow up..................................................................................................35
Limitation.............................................................................................................................35
Future research implication..................................................................................................36
CONCLUSION..............................................................................................................................38
REFERENCES..............................................................................................................................40
APPENDICS..................................................................................................................................45
APPENDIX A: MeSH term..................................................................................................45
APPENDIX B: Data extraction process...............................................................................45

LIST OF FIGURE AND TABLES
Table 1 Inclusion and Exclusion criteria
Table 2 PICO search term which is being used to search Cochran, PubMed and
EMBASE
Table 3 Inclusion and Exclusion Key term which is linked with Covidence.
Table 4 Data extraction process of included studies
Table 5 Difference among included studies
Table 6 Data extraction table
Figure 1 Transthoracic Incremental Monophasic Versus Biphasic Defibrillation by
Emergency Responders
Figure 2 Statistic for each study
Chart 1 PRISMA flowchart
Chart 2 Odd ratio and 95 % CI
1

LIST OF ABBREVIATIONS
AF Atrial fibrillation
EC Electrical cardioversion
RCT Randomized Control Trial
I ampere
OHCA Oklahoma Health Care Authority
2

ACKNOWLEDGEMENT
I would like to express my thanks of gratitude to my ………. as well as our……. Who have given me an opportunity to show
knowledge and skills to do this project on the topic Is biphasic shock being more effective than monophasic shock for transthoracic
cardioversion of atrial fibrillation that also help me in doing lot of new research to find out the conclusion.
Secondly but important that I would to thank my family and friend who help me in order to complete the project with the proper time
frame.
3

ABSTRACT
Background
With transthoracic cardioversion of Atrial Fibrillation, the biphasic shocks are generally more effective than the monophasic
shocks. It is quite essential to know about which care treatment is better among monophasic shock and biphasic shock. As the blood
may pool within cardiac system that eventually enhances the risk of developing clots and can lead to stroke or various other
complications as well. So, to treat such condition among vulnerable patients, there is monophasic and biphasic shocks care treatment
which is quite accurate, include less costing, effective and are able to prevent damage to the cardiac system.
Methods
For effective research the evidence based studies were selected by overviewing the database such as Cochrane Library, PubMed
and EMBASE for up to 20th July, 2022. During the follow-up processes, these primarily observed terminations was the monophasic
and biphasic shocks. Within this, some secondary results observed were cardiac death and frequent vascularization.
Results
In this, there are three RCTs and ten observational studies were including 150 patients per trail. In context with the primary
terminations, comparing the monophasic and diphasic shocks, the confidence interval was mainly found to be about 96%. Atrial
fibrillation was specifically found to be greater due to monophasic shock.
Conclusion
It has been analysed that biphasic shocks are crucial for defibrillation success in a person with out of hospital cardiac arrest.
Biphasic shocks are applicable to minimise the exposure of heart to the high amount of current which improves the treatment
outcomes. Using monobasic shock defibrillation, increases cellular injury, skin side effects and recovery time. Studies found that
biphasic shocks are preferred to perform the cardioversion rather than monophasic method. The overall studies show that biphasic
shocks increase the success rate of the defibrillation in comparison to mono phasic current flow.
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5

INTRODUCTION
What is transthoracic cardioversion of atrial fibrillation?
The atrial fibrillation is defined as irregular and rapid heartbeat or rhythm which is also known as arrhythmia which can lead to
create blood clot in the heart. Atrial fibrillation enhances the risk of stroke, heart of stroke, heart failure and other associated risk
which is showing wider range of complication (Electrical Cardioversion, 2022). Due to arrhythmia, the heart upper chamber named
atria beat out of coordination with lower chamber that is ventricle. The condition which may no symptoms but when sign and
symptoms that do appear which may include shortness of breath and fatigue where they show the occurrence (Fried, Strout, and
Perron, 2021). In this, transthoracic electrical cardioversion which may represent most effective therapy in the conversion of atrial
fibrillation that is AF to sinus rhythm. External cardioverter-defibrillator discharge which is based on current with monophasic and
most recent biphasic waveform. In this, the two shocks are used which is monophasic and diphasic shock. The transthoracic
cardioversion state that shock is proportional to chest wall where monophasic or diphasic shocks is used for condition of arrhythmia to
maintain and regulate normal heart beat (Goldenthal and et. al., 2019).
Why research is important on this topic
As per the above topic, the atrial fibrillation is become common among the population. The people are unware about situation
and such medical condition and face various complication. Sometime, such situation may lead to create the issue which is life
threatening for patient and mortality rate is increases. Therefore, medical science has started their investigated and they introduce
transthoracic cardioversion that is essential in order to make the treatment for the atrial fibrillation. In addition, there are two aspects
are deriving which is related with monophasic shock as well as biphasic shock. The monophasic waveform is usually helpful in order
to deliver the electrical shock in the single direction form one electrode to another with the biphasic shock, therefore, current is also
travel in the two phase as named cleared that concept with biphasic means dual flow. In the first phase, the current runs from the first
electrode to the second electrode via the patient heart.
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Finding from the topic which act as main reason to start the research on topic to carry out the investigation of effectiveness
between monophasic and diphasic shock. The cardioversion is suitable option to treat the atrial fibrillation where rectilinear biphasic
shocks are usually significant that is more effective than damped sine wave monophasic shocks for the transthoracic cardioversion of
atrial fibrillation. The use of biphasic shock is the most significant predictor for the successful approach as a cardioversion. In addition
to this, they enhanced efficacy, rectilinear biphasic shock that is all about cardiovert with less delivered current that have unit counted
in ampere (I). The benefit of biphasic shocks which is most pronounced in patient with the transthoracic impedance that is greater than
70 Ω. In addition to this, these all information and data is well used in order to create the awareness and understanding effectiveness of
monophasic and biphasic shock for different condition. In this, study is based on cardioversion that is pivotal for research in order to
configure the research that is well related with monophasic and biphasic shock which is well interrogated for their effectiveness and
develop the relevance in transthoracic cardioversion. This all reason which take stand to make the proper research in this area which is
functional and derivate new concept that is related with topic difference and effectiveness are used to taken out that is proportional
with monophasic and diphasic shocks that is relevant with cardioversion of atrial fibrillation.
Two type of cardioversion
Cardioversion is medical process which is uses quick, low energy shock to maintain and restore a regular heart rhythm. It is
referring as treatment for certain type of irregular heartbeats that include atrial fibrillation. Therefore, it is also examining various of
time that cardioversion is used as medication. The cardioversion is usually having process where schedule is used to taken in advance
and sometime it is done on emergency basis. Cardioversion quickly restore a typical heart rhythm. In this, there are two type of
cardioversion is used which help to correct the heart best which is too fast that is tachycardia or irregular that is fibrillation (Gupta and
et. al., 2019).
Two cardioversion type are helpful to maintain the issue of irregular heart and atrial fibrillation (Anticoagulation in Atrial
Fibrillation Cardioversion: What Is Crucial to Take into Account, 2021).
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Electric cardioversion: It is generally uses a machine or sensor which consist of electrode in order to deliver instant low energy
shock to patient in their chest to recover a condition that is associated with improper heart beat which is irregular in manner. The
electric cardioversion allows healthcare provider to make the instant procedure which is useful to restore the typical heartbeat.
Chemical cardioversion: The chemical cardioversion which is also known as pharmacological cardioversion that uses medicine with
aim to restore the heart rhythm which is irregular in manner. It also taken longer to work than electric cardioversion. In addition, the
healthcare provider suggest cardioversion with the proper medication which is useful for patient to restore the condition that related
with cardiac arrhythmia. It is also referring as alternative situation from shocks (Nuqali, Shafiq, Syed, and Sheikh, 2018).
In addition to this, difference between monophasic and diphasic is well analysed where monophasic is given in only one direction
from electrode to the other. In the biphasic shock, initial direction of shock is revised on same path by changing their polarity of
shock. Therefore, the initial voltage is applied which is higher than the reversed polarity shock (DIFFERENCE BETWEEN A
MONOPHASIC AND BIPHASIC DEFIBRILLATOR, 2014).
Need of transthoracic cardioversion of atrial fibrillation
The electrical cardioversion is also help in order to make the several abnormal rhythms. In this, it is most commonly used to
treat atrial fibrillation. As per this, it is also analysing that atria of the heart quiver instead of beating the right ways. There are some of
symptoms which is related with the atrial fibrillation including shortness of breath, fatigue and fast heart food. It is also enhancing the
chances of stroke. Therefore, the regular condition of irregular heart beat can lead to create critical condition which require electrical
cardioversion which is also powerful in order to manage and treat heart rhythms, they are like atrial flutter, related with atrial
fibrillation. In addition, it is also used in order to make the certain kind of supraventricular tachycardia and ventricular tachycardia.
There are some of the heart rhythm which cause the issue of heart rate that is generally too fast. It also used to prevent the heart from
the pumping enough blood. There are some of the process where soft electrode pads are placed on chest. It might need some of area of
skin that is shaved to get the electrode pad to stick. These electrodes will connect to cardioversion machine, using the cardioversion
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machine programmed high energy shock that is sent to heart. It is also convert the heart beat to the normal range (Vernemmen and et.
al., 2020).
Aim
The main aim of study is well determining whether either monophasic or biphasic shock was more effective for transthoracic
cardioversion of atrial fibrillation.
Objective
 To investigate and compare the effectiveness of monophasic shock or biphasic shock for transthoracic cardioversion of atrial
fibrillation.
 To identify the procedure that is monophasic shock and biphasic shock for transthoracic cardioversion of atrial fibrillation.
Research questions
Is biphasic shock being more effective than monophasic shock for transthoracic cardioversion of atrial fibrillation?
Alternative Hypothesis
There is predominant difference between the monophasic shock and biphasic shock in transthoracic cardioversion of atrial fibrillation.
Null hypothesis
There is no predominant difference between the monophasic shock and biphasic shock in transthoracic cardioversion of atrial
fibrillation
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METHODOLOGY
Criteria for eligibility
The eligibility criteria in the investigation section can aid to define the specific protocol that is used by the analyst while
conducting the search. In contrast with the clinical trials, the need which must be met for an individual is well involved within the
trail. In reference with the investigation procedure, a systematic and meta-analysis is generally used to take which must be configured
important elements which is associated with the study work. In addition to this, each of the review mainly involve a specific protocol
that is need be followed in an appropriate pathway which can produce an ethical consideration for selecting significant data or
information. the criteria for the eligibility is well involve an inclusion as well as an exclusion criterion that can exhibit detail or a
procedure for choosing and for the qualification of study work. However, the provided table is all about exclusion and inclusion
criteria which can describe in a qualified contrast and is undertaken among the investigation procedure and process as well. In addition
to this, the Table 1 mainly illustrate inclusion and exclusion criteria.
Table 1: Inclusion and Exclusion criteria
Inclusion criteria Exclusion criteria
 English language is compulsory while
doing the research or review which is
mainly based on both systematic and
meta-analysis.
 The studies mainly involve systematic
review which is associated with the
literature review and specifically
configure to meet the following
inclusion criteria. It is generally the
 There is no other language apart from
English taken under the research
process. however, other languages are
effectively taken within the exclusion
criteria.
 In this, there are some specific
investigations which were available
freely as it can need monetary funds in
order to begin that is effectively
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meta-analysis and a systematic review
where the possible risk of bias is
greater and it must be abandoned within
each research.
 The patient with cardiac arrhythmia is
mainly undertaken within the
investigation in order to effectively
measure the mechanism and
effectiveness of transthoracic
cardioversion among them.
 However, cardiac arrhythmia is
generally more common among the age
60 and above. The majority of
information is gathered from specific
articles or journals which considered
age groups for the study.
 The effective interventions that is taken
for the cardiac arrhythmia where reason
to effectively analyse the effectiveness
and necessity of research in an
appropriate pathway.
 Dysrhythmia among people is grown as
excluded from the research and are also
not available for the reviewer as well.
 Apart from monophasic shock or
biphasic shock for transthoracic
cardioversion of atrial fibrillation, no
other care interventions are being used
to taken the Randomized Control Trial
(RCT).
 A Cohort study, an experimental study
and many more is well excluded from
the investigation it is because the major
review procedure is efficiently based
over systematic and meta-analysis
literature review.
 The mechanism which can follow the
non-pharmacological approaches or the
effective interventions is not
undertaken in the study work or review.
the main cause behind the exclusion is
that they are inaccurate and create
aspect that is concentrated on more
traditional aspects which have less
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a problem which can last from hours to
several years and can exhibit high
mortality rates and complications as
well. Within research, the people with
dysrhythmia is mainly engaged within
the investigation for the study of
effective mechanism such that how the
pathophysiological functioning can
contribute during the dysrhythmia to
know the effectiveness of both
monophasic shock or biphasic shock
for transthoracic cardioversion of atrial
fibrillation. To one side, no other
patient with any of the complication is
being taken under the research, the
inclusion criteria is mainly determining
the effectiveness of monophasic shock
or biphasic shock for the transthoracic
cardioversion of atrial fibrillation.
 The investigation is mainly taken from
the secondary sources where the
Journals, articles, grey literature and the
likelihood of action potential.
 The articles above 15 years of the
publication date which is linked with
the research topic are effectively
excluded.
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peer-reviewed paper are outlined as per
published in the last 12 years in order to
ensure the information that is up to date
as well as the information is well stated
towards the tool which is recently
executed within the healthcare for the
care treatment of atrial fibrillation.
 Additionally, every investigation that
will display effective information or
data is well linked with the PICO
framework which is executed within
the review.
These such above discussions can produce a relevancy in context with the knowledge of both inclusion and exclusion criteria
for collecting the attention in order to receive understanding about the investigation that what type of data should carry out while
directing the study. In addition, the eligibility criteria can effectively enable analyst to make significant procedures while conducting
the study in order to avoid the collection of such information or data irrelevant to the research problems or the research topic that is
sufficiently selected for the investigation work.
Source of information
Data Sources are much more reliable to give specific data in context with effective resources which is used during the study
work in order to extract or collect the information. In context with the study work, the database is highly used which work is
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researched fraction in order to obtain the validated Journals and articles for the systematic review. In addition to this, the database
such as Cochrane Library, PubMed and EMBASE. These are the most trusted and reliable web sources in order to collect the effective
data from Journals and articles more specifically for the clinical study. In this, while gathering the effective information from PubMed,
the filter is mainly implemented that is linked with the published article in the last 15 years and Randomized Control Trial as well. It is
quite necessary apply the filter with a cause that it is a part of an inclusion criteria. Within this, the above 15 years and more published
articles is excluded from the research such that while finding the articles for the data, filter can be implemented to follow effectively
the inclusion criteria. However, it can aid to give a proper information relevant with the research in order to make an ample evidence
based on the explanation from PubMed database. Similarly, Cochran database is mainly used for the extraction of information where
the most relevant article is present. As similar with PubMed, the filter is generally applied for the year which is from 2015 to 2022.
However, the research must be reliable so that they can be made under the effective trail sections. While performing the screening
procedures, most of the research is not refer where the Randomized Control Trial is excluded. With this, EMBASE database is also
being used as a suitable platform in order to extract the relevant information about the research topic, and the filter is implemented and
article is being chosen more specifically a systematic literature review. Within this, the last search on the Cochran and PubMed
database is generally occurred on 1st August 2022. In this, the PICO search term is the major configuration as a diabolical search
though the 2 databases that are exhibited in the Table 2. The MeSH term is being produced as well as is well studies in the PubMed
for the appropriate selection and gathering of the information.
PICO framework
Table 2: PICO search term which is being used to search Cochran, PubMed and EMBASE.
Patient Patient more than 60 years with issue atrial
fibrillation.
Intervention Monophasic shock or biphasic shock for
transthoracic cardioversion.
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Comparison None
Outcome Recovery of Patient and enhance level of
comfort after the monophasic shock or biphasic
shock for transthoracic cardioversion.
Screening of studies
After studying via several effective resources prominently determined as Cochran, PubMed and EMBASE database. However,
the search outcomes are well imported using systematic review software called covidence. Within this, while explaining the
information when duplicacy is being removed, screening of the research title and abstract mainly initiate there is only the review per
the searcher is worked independently to screen via all the outcomes. Furthermore, the keyword list is mentioned below in the table 3
which can exhibit the screen via abstract and title. In addition to this, such keywords can configure the information or data again with
the aid of effective keywords that is determined below. However, Covidence can also display their possible capability highlighting the
specific words that can made the reading much faster and more effective. With this, for the screening of studies the proper software is
used with the configuration for studies. Covidence is used commonly where topic is divided in fixed keyword and search pattern is
follow that is full text article or journal that provide eligible knowledge that plotted within the report. In context to procedure which is
predominantly used for the data extraction and data configuration are showing the path which is best applicable for the extraction of
data that provide suitability for software term. The keyword and MEsh term are generally used to collected suitable process for data
extraction and elucidation.
Table 3: Inclusion and Exclusion Key term which is linked with Covidence.
Inclusion criteria Exclusion criteria
 Adults.
 Atrial fibrillation.
 Monophasic shock or biphasic shock
 Non pharmacological.
 Young people.
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for transthoracic cardioversion.
 Cardiac Stroke.
 Heart failure.
The title and abstract that is being reviewed as well as displayed the relevancy that is accessed, full text screening is also began
with the beginning of the research. while conducting the research, specific approaches as well as the result is mainly concentrated that
is appropriate to make the proper studies for explanation of the specific information and data as well. Within this, the trails are
generally needed some study that is linked with the vulnerable patients suffering from atrial fibrillation. The research has some of the
basic needs where the inclusion is used to made as well as involved within the research. It can also experience that the extraction of
the information section is well exhibited the relevancy where the appropriate data in context with the investigation is being extracted
as per the vision of various other author. It is generally undertaken for all the investigations which is determined to meet the inclusion
criteria or generally include the factors of exclusion criteria, then it was removed as well as exhibit the cause that is well given for the
research topic or the hypothesis that is necessary to prove effectively.
Quality assessment and data extraction
Quality assessment is generally defined as a tool or technique that is mainly undertaken to exhibit the devise structure which is
diabolical within the terms where they can encourage the information in sufficient amount and measure the quality after every review.
Within this, the review is generally start with the literature and the chosen article articulated for the collecting an effective data or
information. In addition, the quality assessment and the extraction procedure appropriate with the information is initiated when the
screening of the research is finished. The screening as well as various other tactics that is generally used by the software and is
mentioned above with name Covidence. It is significantly analysed that the use of database such as Cochran and PubMed is
considered the most reliable to exhibit the risk formulated from the Cochran database for the bias criteria. However, the quality of
every research involved within the study work is well addressed. Furthermore, when review is effectively defined, the complete
16

assessment is being transmitted to review the leader. It is specifically enabled for the formulation of the summarised figure that can
depict within the contrast to colour that is given effective instructions for the bias (The green circle is indicated with low risk, yellow
is indicated as unsure and red is depicted as a high risk). Within this, the data extraction procedure is mainly found with explanation of
the article from the Cochran, PubMed and EMBASE database. Furthermore, the data extraction procedure is mainly seen within the
Appendix B.
In the Table 4 provided below, the data extraction process from the chosen research is well taking into reflection where the
results and information is being plotted. In addition to this, the researcher generally used to review the information and analyse the
missing information and data that can missed while conducting the review procedure.
Table 4: Data extraction process of included studies.
General José Francisco Secorun Inácio and et. al., 2016. Country chosen for
investigation is United Kingdom.
Participants 3046 patients, 5 biphasic and the monophasic waveform were
taken within the research, mean age is approx. 60 years
(Monophasic and biphasic shock for transthoracic conversion of
atrial fibrillation: Systematic review and network meta-analysis,
2016).
Intervention/comparison Monophasic or biphasic shock is more effective for transthoracic
cardioversion of atrial fibrillation.
Outcome The initial outcome of Monophasic shock or biphasic shock is more
effective for transthoracic cardioversion process help to prevent the
event of atrial fibrillation.
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General Steven C Faddy, Paul A Jennings, 2016
Participants The participant is selected on the basis of randomised control trials
also known as RCTs which is well compared with biphasic and
monophasic waveform defibrillation among the adult with OHCA.
There are two review that the author is using independently
showing the process of screening where the literature search is well
used as produce the results. Therefore, the four trials
are conducted and 552 participants is selected in order to compare
biphasic and monophasic waveform among people with OHCA.
Intervention/comparison The comparison is used to made that is uncertain as per author point
of view whether biphasic defibrillator that is important and show
effect on defibrillation success in the people with the context to
OHCA. In addition, it requires large studies that help to show the
adequate and statistical power.
Outcome It shows the effect of biphasic defibrillation on the success of
people with OHCA.
General Aleksandr Voskoboinik et. al., 2018
Participants 125 patients are undertaken within the research process where a
randomised control trial is used. In addition, shock vector and MPA
is successfully taken which is help to make the patches on it.
Intervention/comparison The routine use of patches at 200 J is an adequate in obesity.
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Therefore, strategies are used to improve the success including
using paddle, MPA and escalation which is about 360 J.
Outcome The outcome is analysed as paddle is successfully converted into
the 68 to 82 patient that compared with 46 of 69 using the patches.
Therefore, the shock vector is not influence first and second success
rate. The energy required for the progress of the result is counted as
approx. six to seven cases.
Heterogeneity
The research undertaken among the process is well given with the aspects that display the importance of monophasic shock or
biphasic shock for the treatment of transthoracic cardioversion procedure that can aid to prevent the events of atrial fibrillation.
However, the initial outcomes are well measured with the treatment of transthoracic cardioversion procedure which is useful to
prevent the encouraging dysrthymia. Among all the participants with atrial fibrillation that has been undergone to the heart procedure,
most of the participants have continued to gain or can receive an ongoing antithrombotic care therapy, however, the elevated risk of
cardiac arrest or cardiac failure that is lower with the associated illnesses which can contribute to cause the of illness as well as can
involve a key part in its development and the response towards treatment. Furthermore, the variance that is linked among the selected
studies which have been well-known in Table 5 provided below.
Table 5: Difference among included studies
Participants Transthoracic cardioversion
procedure to prevent atrial
fibrillation
Anti-arrhythmic medications
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The primary analysis of the
participants is well involved
3046 participants that is
generally outline for
investigation in the group. The
mean age of the participant is
about 60 age years.
Cardioversion is generally a
clinical process that can use a
quick, low energy shocks to
restore a regular heart rhythm.
It includes various types of
irregular heartbeats such as
arrhythmias, consisting of
atrial fibrillation. In some
conditions, the cardioversion
can be done by using
medications.
The drugs are mainly used to
keep a normal rhythm of the
cardiac system, not just to
regulate the heart rate. It is
because they generally tend to
have more side effects than the
medications which can control
the rhythm of heart, anti-
arrhythmias specifically tend
to be used more sparingly.
Statistics
With help of using specific tool which can aid to give the effective information or data that is well associated with the study
topic. The topic is to concentrate over the necessity of monophasic shock or biphasic shock for the treatment of transthoracic
cardioversion procedure that can aid to prevent atrial fibrillation events. Within this, the statistic is specifically plotted with the aid of
forest plot. In context with forest plot, it is generally known as a blobbogram that is useful to make the effective graphical
representation of the measured results from various scientific investigations to effectively address the similar query along with the
results that is effectively elucidated. In context with Transthoracic cardioversion procedures involve some of the results defined by
several articles in various pathways. Within this, they are generally adequate to give the information and the results which can exhibit
the outcomes generally driven by longer path. Overall, the main aim to use the monophasic shock or biphasic shock as biphasic shock
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are considered as more effective for the endocardial defibrillation than monophasic shocks. Furthermore, it is identified that biphasic
shock does require less energy for the same efficacy.
Figure 1 Transthoracic Incremental Monophasic Versus Biphasic Defibrillation by Emergency Responders.
Source: https://www.ahajournals.org/doi/10.1161/circulationaha.106.636506
As per the view point of forest plot, it is well determined that the use of forest plot is required to compare the efficacy of
monophasic vs biphasic shocks for transthoracic cardioversion of atrial fibrillation. In addition, the forest plot used to determine the
various fact and figure showing the proper plot that is well related with the topic. The forest plot used to provide level of study related
with comparative factor among the monophasic and biphasic shock for atrial fibrillation. In addition, it challenging to create forest
plot for the study but some simple fundamental is used in order to plot the graph which help to provide wide range of study that is well
related with the topic where proper forest plot is introduced.
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Forest plot:
Study name Odds ratio Lower 95%CI
Graph lower 95%
CI Upper 95%CI Graph upper 95% CI position
Study 1 1.9 1.1 0.8 3.1 1.2 0.5
Study 2 1.2 0.9 0.3 1.5 0.3 1.5
Study 3 1 0.6 0.4 1.7 0.7 2.5
Study 4 1.2 0.5 0.7 2.9 1.7 3.5
Study 5 2.9 1.1 1.8 7.6 4.7 4.5
Study 6 1.13 0.6 0.53 1.9 0.77 5.5
Study 7 1.53 0.9 0.63 2.3 0.77 6.5
Study 8 1.8 1.2 0.6 2.7 0.9 7.5
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RESULTS
PRISMA flowchart
PRISMA flowchart is undertaken as the forms of flowchart utilised for reporting the systematic reviews as well as meta analysis.
Additionally, this states the evidence backed explanation transparently so that users may simply and wholly acknowledge. The review
of users uses this into several types of studies, basically the area which needs evidences such as medicine and others. Moreover, the
collection, progressing and analysing the data within research papers sis an ideal stage for suing the particular flow diagram. This
implements the reference investigation chosen as well as exclusion of research which are not effective to its topic. Prism concentrates
upon evaluating the systematic reviews for raising the report value. Developing diagrams into reviews updates is not much difficulty,
but this needed preparations as well as essential data sources study. In addition to this, there are two key elements such as items
checklists as well as flow diagram. The 27 checklists of item incorporate title, summary, methods, outcomes, discussion and cost of
further studies. The flow diagram renders the final meta evaluation depending upon the reporting standards. The intent of using prism
flowchart is to maximise review the value. Mainly checklists as well diagram of flow chart in detailed manner and assists the report
attain higher relevancy. Also, referencing the reviews as well as meta analyse assures explicitness and clearness of report. This forms
of flowchart are crucially preferring into health care areas since this synthesizes the finding of various research, in that way
summarising the efficient availability of investigation. Furthermore, this can also be helpful for critical evaluation of published
systematic reviews, though this is much a quality evaluation instruments for gauging the systematic review quality.
The chart title show that there is no derivation which may provide in depth learning towards topic that is well associated with
sudden factor that contribute towards the study. Apart from this, above mentioned Figure 2 that is showing wide range of statistic that
provide the description odd ration, lower limit, upper limit, and P value. As per the chart that is mentioned in the report show
description, it shows the odd ratio as per comparison with monophasic as well as diphasic shock for transthroacic cardioversion of
atrial fibrillation. The study says that Steven, Jose and Aleksandr, where study is used to place which may provide set of data and
information which is well related with the current context that allow research to interpret the data that show a wide range of people
23

used to taken that insist the contempt of review that show information reading with effectiveness that consist of comparative study of
monophasic as well biphasic shock that show a range transthoracic cardioversion which is suitable for atrial fibrillation. As per the
chart of odd ratio, the Jose of higher as comparison with other on other hand, Jose is also higher in upper and lower limit of study that
allow to make sense of the result. It also analyses that P value is lower with the respect to Jose.
24

25
Records identified from*:
Databases (n = 240)
Registers (n = 120)
Records removed before
screening:
Duplicate records removed (n
= 120)
Records marked as ineligible
by automation tools (n = 90)
Records removed for other
reasons (n = 45)
Records screened
(n = 90)
Records excluded**
(n = 45)
Reports sought for retrieval
(n = 45) Reports not retrieved
(n = 30)
Reports assessed for eligibility
(n = 20)
Reports excluded:
Reason 1 (n = 30)
Reason 2 (n = 15)
Reason 3 (n = 10)
etc.
Identification of studies via databases and registers
Identification
Screening

26
Studies included in review
(n = 30)
Reports of included studies
(n = 5)Included

Quality assessment
Quality assessment is regarded as the collection and analysis of data by tat the degree of conformity to pre-specify standards as
well as criteria are exemplified. In case the quality, by this procedure is identified to be unsatisfactory, attempts are developed for
discovering the cause for it. Additionally, the evaluating the evidence quality included into a systematically reviews is as vital as
assessing the information into it. Outcomes from badly performed research may be skewed through biases from research methodology
as well as might be interpreted with caution. Such investigation could be undertaken as those into the systematic review or absolute
disqualified. In addition to this, the choosing an effectual technique to aids evaluate the strengths evidence as well as imbedded biases
into all papers is also vital. Additionally, the study assessment provides an indication of evidence strength facilitated through it review.
This aids in ascertaining either the investigation is vigorous much for guiding treatment, prevention, diagnostic or policy decisions.
Data extraction table
Data extraction is considered as the procedures through which investigators gain the crucial data related to study characteristics
and findings from the incorporated studies. Additionally, the data extraction is linked to evaluation of research quality into that both
procedures are often considering at similar period.
Table 6: Data extraction table
Title Author Year Country Patient
age
Study
design
Sample
size
Result
Transthoracic
Cardioversion
of Atrial
Fibrillation
Comparison
Suneet
and et.
al.,
2022 New York 50 to 60
years old
Randomised
control
trials
174 patient Regarding
effectiveness,
the rectilinear
biphasic
shock is more
27

of Rectilinear
Biphasic
Versus
Damped Sine
Wave
Monophasic
Shocks
effective than
sine wave
monophasic
shocks.
External
cardioversion
of atrial
fibrillation:
comparison
of biphasic vs
monophasic
waveform
shocks
Richard
et. al.,
2001 United
State of
America
Unknown Randomised
control
trials
57 patients
are
selected as
sample
participants
for report.
Study revel
that with the
same energy
level of 150 J
the biphasic
impedance is
high
compensating
waveform
shocks are
more superior
to
monophasic
damped sine
waveform
28

shocks as
cardioversion
of AF.
Comparison
of
monophasic
and biphasic
shocks for
transthoracic
cardioversion
of atrial
fibrillation
Scholten
et. al.,
2003 Netherland Unknown Prospective
randomised
study
109 patient
is selected
The
monophasic
waveform
shocks in
200-360 J
sequence has
the same
efficacy 90
percent as the
part of
protocol
using the
rectilinear
biphasic in
120-200 J
sequence.
29

DISCUSSION
Risk of bias: ethics
There is generally ethical consideration that can lead to influence the study results and must be taken within consideration as
well as should effectively avoid the possible risk of biasness. It is generally necessary to take care of better as well as an effective
response that is positively linked with ensuring about the ethical concern where the informed consent is greatly essential. Prior the
research, it is quite necessary to take an informed consent from all the participants who are positively involved within the research
procedure. In this, getting an informed consent is generally ethical concern as well as must not biased which can aid to provide a
creditably of the investigation. There is also need to take care that each of the participants must get an informed consent as well as can
have all the necessary information that is needed to have. It is necessary to take care of all the elements during the research procedure.
While talking about ethical biasness, it is important to ensure that taking care of every component which is involved within the
delivery of better understanding and can ensure about utilising that specific information in order to get better results. In addition, here
the risk of bias within the investigation can be misled in order to correct the study results as well as can create the research issue. Here,
it is also required to ensure about taking care of the better as well as an effective response that are linked with the collection of
accurate data that is quite necessary and must give a positive response. While doing the research, there is also a need to ensure that the
study design or collecting the information must not be effectively biased as well as can have an accurate data which can be relevant
and can aid in getting an effective study results which can be used for further investigation or the practices as well. The researchers
must ensure that the study ethics must not be bias that can efficiently mislead towards the research response and can lead to produce a
false result. In addition to this, there is also a need to take care about an efficient response where the possible risk of bias can lead to
alter the study results. While doing the investigation, all the ethical considerations followed, can effectively aid to get the accurate data
as well as can enable to give an enhanced response to the investigation process. Furthermore, the research has also taken care of the
study response that are effectively linked with ensuring the following ethics which can involve a positive outcome itself.
30

Summary of finding
According to the above report, a cardioversion efficacy is about 90 percent, however, patient of cardioversion differed
remarkably from the patients who take electrical cardioversion in the present era in that their sufferer were younger, numbers of
patients had disease like rheumatic mitral valve illness, and number of patients were getting treatment by quinidine. In disparity, those
patients who were older, had a mixed atrial fibrillation, cardiac origin, and were getting a numbers of different anti-arrhythmic drugs,
such as amiodarone and so on. According to the, recent study, it was reported that potential of the monophasic shocks to the
cardioversion in case of atrial fibrillation had vary broadly, and it ranging to 96 percent from 38 percent. These variations broadly
display the differences in the control characteristics suffers choose to cardioversion (Schneider, and et. al., 2018). As per the above
study, previous studies have reflected that an enhanced transthoracic impedance and a large period atrial fibrillation predict
unsuccessful cardioversion. In the above study, the dominance of the rectilinear wave form of biphasic on the damped sine wave of
monophasic waveform was illustrated in two groups who were identical at the baseline mainly concerning reported variables for
impact success of shock, consisting impedance of transthoracic, duration and weight of atrial fibrillation. In terms of the transthoracic
procedures of cardioversion including some of the outcomes that is described by the various pathways in numbers of articles. In total,
the major goal for utilization of the biphasic shock and monophasic shock like biphasic shock are thought about as more impactful to
the endocardial defibrillation in comparison to the monophasic shocks. It Is recognising that the biphasic shock waveform need very
less potential to generate the same efficacy as monophasic shock (Olsen, and et. al., 2019).
Raw data
In order to perform the study in an advanced manner, extracting an effective information is generally one of the essential highly
effective task lead to give a better response for a positive result. In this, it can also aid in getting an advanced care as well as can
enable to enhance the study area in a positive pathway. While conducting the study over specific topic, there was a requirement of
several resources which can be authentic as well as can involve an advanced outcome in collecting the quality of information for a
high response. Within research, the raw information was required in order to gather that was interpreted above to get a high response
31

as well as can enable to get healthy data via such gathered information. In addition, there is also a requirement to take care about the
specific positive outcomes which can effectively aid in getter advanced care and enable to give higher results within the study process
as well. There are various different sources which was visited where the internet as well as online platform were greatly effective and
can enable to give an abundant information. There are PubMed Central, EMBASE, Cochrane and many more databases which can
play an essential role in providing an abundant information regarding the study topic. Within this, various Journals, Articles can
enable to give crucial information about the relevant research topic in an advanced manner. Furthermore, there was also required to
ensure about an effective response that are quite effective and is required to take care via using mails, internet as well as various other
sources which can enable to collect additional information via taking care of effective and better response and effectively help to give
enhanced outcomes within the research.
Similar studies
According to the perspective of M Scholten et. Al, 2016, The main techniques of choice for restoring the rhythm of sinus in
suffers with long time atrial fibrillation is external electrical cardioversion. Recently, external defibrillators provide monophasic
shocks of damped sine waveform. Although, it has been represented that an even or comparable higher pace of transthoracic
cardioversion may be gained through biphasic shocks. All these studies evaluated that potential utilising step up rules and protocols
initiating at very low level of energy (LISKOVA, and MANKOVECKA, 2022). Although, 75 percent of the sufferer can be
successfully cardioverter through the present recommendation to 200 joule starting level of potential utilising waveforms of
monophasic shock. 70 percent of 109 suffers were treated with a starting 200 joule monophasic shock were are used for the
cardioversion for sinus rhythm, as compared with 80 percent of 118 suffers treated with a starting potential 120 joule biphasic shocks.
After the 2nd shock of 200 joules for biphasic and 360 joules for monophasic, 90 percent of the suffers were in sinus rhythm in each
groups. The mean of cumulative potential utilised to fruitful cardioversion was 159 joules to biphasic shocks and 306 joules for
monophasic shocks. Cardioversions were completed after the utilisation of deep sedation utilising weight adjusted I.V ethomidate and
diazepam in the state of post-absorptive. The comparisons of biphasic and monophasic shock efficacy are, monophasic require
32

initially 200 joule and biphasic shocks waveforms need 120 joules initially. To the electrical cardioversion of the atrial fibrillation, a
rules or protocol utilising monophasic shocks of waveform in a 200 to 360 joules sequences and in biphasic shocks of waveform using
120 to 200 joules sequences which has similar potential as monophasic waveform (Jones II, and Berger, 2020).
Follow up period
Activities/Months February March April May June July August
Introduction
Aim and objective
Literature review
Methodology
Results
Discussion
Conclusion
Submission
Here, time plan basically include the information about the research topics which are covered in a particular time duration. In
this, time plan can solve the same problems, but more advanced choices of the activities which are left open. It should be chosen with
their scheduling, highly provided with the specific actions and their impacts as well. Within this, the study topic discussed above
mainly starts within the month of February with involving introduction about the concept of whether monophasic and biphasic shocks
better for transthoracic cardioversion of atrial fibrillation. In this, an external electrical cardioversion generally remains the effective
technique of choice for effectively restoring the sinus rhythm within the vulnerable patients with involving persistent atrial fibrillation.
Within the research, the most recently used external defibrillators can deliver an effective monophasic damped sine waveform shocks.
Therefore, it has been depicted by the care treatment that a comparable or greater rate of the transthoracic cardioversion that can be
33

accomplished with the biphasic shock. In addition to this, the biphasic shocks are generally more effective for the endocardial
defibrillation as compared with the monophasic shocks. For the transthoracic ventricular defibrillation, the biphasic as well as
monophasic shocks are similarly effective, but while talking about biphasic, the shocks can need less energy for the same efficacy. In
addition to this, in the month of April and May, the information is being gathered from various sources such as Articles, Journals and
online as well. The efficient data has been collected which involve the information regarding which care treatment is better such as
monophasic or biphasic shock for the atrial fibrillation among patients. By the end of the month July and August, relevant information
is considered for the research process and involve various biasness and unbiasness during the whole process.
Method based on follow up
Within the research, the methods which are being used can cover the chosen research topic can involve such as screening of the
studies, criteria for eligibility, the Quality assessment along with data extraction. In addition to this, there is also a Heterogeneity and
statistics and every research mainly involve an effective guideline that is called as the eligibility criteria. It can describe the specific
characteristics that must be shared by every effective participant. In addition to this, a Follow-up investigation generally happen after
the study or a therapeutic treatment which has been effectively presented to the participants which are involved within the research. In
the research, there is a meta-analysis that was efficiently attained by using several methods with help of review the leader for an
effective statistical analysis. Furthermore, there are the tools that specifically assess the potential risk for the biasness, the
identification biasness, performance biasness and many more. Moreover, the review was effectively conducted as the preferred
reporting items for the specific systematic reviews and meta-Analysis such as guidelines of PRISMA and so on.
Limitation
However, the results are compatible with one experience's report together with the biphasic shock, these may not have implicated
to another device which utilize alternate waveforms of biphasic. The study was not double blind, due to the utilization of various
defibrillators. On the basis of modern day study and other statistical data, this is appropriate to take consider what rules and protocol is
proper to selective cardio-version of atrial fibrillation utilising a waveform of biphasic shock. Since there are no any available data
34

exhibiting that injuries related to cardiac outcomes from the shock potentials of up to 200 joules biphasic, another could recognise
utilizing 200 joules as the proper primary choice; in fact, this may be proper to patients with atrial fibrillation less than one-year
period. Apart from this, 150 joule displays to have about 80% chances of the success. Therefore, it reflects an appropriate compromise
between the aspiration for restrict any probability deleterious potential impacts on the myocardium and the organised achievement of
conversion (Buchan, and et. al., 2021). However, failure with this first shock would permit enhancing to 200 joules. Ultimately, to
atrial fibrillation of more than 48 hours’ period, a first shock of 100 joules could be justified, like it outcomes in 80 percent
conversion. Free from the initial selected potential, if 200 joule is not successful in conversion, another may think about alternate
placement of electrode (van Loon,and et. al., 2020). However, studies related to the impact of placement of electrode have gained
mixed outcomes in some cases replacing the position of electrode results in fruitful conversion when previous one unsuccessful.
Therefore, after two or one failed attempts of cardio-version with 200 joule biphasic shocks of waveform, one might think about
changing the electrodes placement for an anterior site administration of an agent for anti-arrhythmic prior delivery of repeated shock,
even catheter cardio-version or double shocks (Handa, and Ng, 2021).
The patients number was limited but as compared with past report, it was larger. Statistical data were incomplete related to the
period of the present episode of atrial fibrillation, a familiar predictor of fruitful cardio-version. However, it was clearly demonstrated
that similar potential could be gained through less provided energy utilising waves of biphasic shock. They did not try to evaluate the
effects of biphasic shock, on the function of atrial, involving differences in the improvement of atrial stunning.
Future research implication
Further studies are need to be conducted or required to analyse the risk associated with biphasic current flow to the treatment of
atrial fibrillation. Due to less cellular injury and recovery time a biphasic current flow method can be applicable for the treatment of
atrial fibrillation. Biphasic current flow is more effective than other methods used for the cardioversion as it induces less skin side
effects. It can be also helpful to restore the normal cardiac rhythm. Less energy and current requirement make it more effective to
regain normal rhythm. It can be also impactful to treat many more cardiac diseases associated with sinus rhythm. Further many
35

clinical studies are being conducted to determine the application of biphasic shocks of waveform to the treatment of various kinds of
cardiac diseases. Studies are being conducted to minimise the risk associated with the delivery of high level of current via heart
chamber during the defibrillation (Brandes, and et. al., 2020). To reduce the cardiac morality several clinical trials, require to be
perform to determine the accurate amount of the current required for the defibrillation. Further defibrillation expansion is required to
detect the actual location of cardiac arrest in the patients who require atrial defibrillation. It is requiring to recognise the patients at the
risk for the further events to minimise the risk related to the ongoing treatment. It is clear that there is no any effective solution to the
huge part of population who are at risk. Therefore, further expansion of the defibrillation process in public are is required via further
studies about these cardioversion treatments. Further studies increase the success rate in preventing or decreasing the sudden cardiac
arrest due the atrial-fibrillation. Therefore, these successes are depending on the ability to identify the subjects which is responsible for
these risk for future events and to decrease the adverse risks and effects which are related with the present treatment of cardioversion
(Aras, Rogers, and Efimov, 2021)
36

CONCLUSION
From the above dissertation, it can be concluded that biphasic shock is comparatively more effective than mono phasic shock as it
requires less energy to treat endocardial fibrillation. Cardio version refers to the method which is applicable to restore the normal heart
rhythm by delivering a low level of current flow via the heart. Studies found that mono phasic waveform provides uni-directional
electrical shocks whereas biphasic shocks delivers electrical shocks in two phases. During first phase, current travel via first electrode
to second one. A protocol applying rectilinear biphasic waveform shocks in a 120-200 J sequence has equal efficacy as the protocol
applying mono phasic waveform shocks in a 200-360 J sequence. Applying the rectilinear biphasic shock waveform equal potency is
gained with lower energy delivered. However, further studies are required to determine the potential benefits of lower energy delivery
for defibrillation. Many experiment are still being conducted to determine the efficacy of the both the shocks. It is found that biphasic
shocks delivery causes less myocardial damage and burns compared to mono phasic shocks. Evidences show that with the delivery of
biphasic shock, the success rate of first shock is 90% where in case of monobasic shock it decreases to 60%. due to less atrial damage
biphasic shocks are considered as more effective treatment for the defibrillation. Success rate of mono phasic defibrillation depends
upon the capability of defibrillator to produce required amount of current flow via the heart for the treatment. Biphasic shocks deliver
lower level of electrical threshold level, increasing the chance for a successful defibrillation. Biphasic shocks are considered as most
applicable tool for the defibrillation as the highest efficacy is achieved with the minimum amount of current and energy.
Biphasic shocks are applicable to minimise the exposure of heart to the high amount of current which improves the treatment
outcomes. Using monobasic shock defibrillation, increases cellular injury, skin side effects and recovery time. A graphical
representation has been given based on comparison between Transthoracic Incremental Monophasic and Biphasic Defibrillation.
Studies found that biphasic shocks are highly applicable because of increased success rate. Biphasic shocks are preferred method for
the defibrillation due the combination of decreased current flow requirements and increased efficacy. Risk associated with the both the
methods has been analysed in this dissertation. For the clinical studies, different age group participants were involved to determine the
effectiveness of both the methods for trans thoracic electrical cardio version of atrial fibrillation. Results shows that biphasic shocks
37

are more effective in the treating most patient diagnosed with arterial fibrillation. It has been analysed that biphasic shocks are crucial
for defibrillation success in person with out of hospital cardiac arrest. Studies found that to perform the cardio version, biphasic shocks
are preferred rather than performing mono phasic method. The overall studies show that biphasic shocks increase the success rate of
the defibrillation in comparison to mono phasic current flow.
38

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43

APPENDICS
APPENDIX A: MeSH term
Population “Older people” [MeSH Terms] OR “Older” [All Fields] OR “old” [All Field]
OR “adults” [All Field]
“atrial fibrillation” [MeSH Terms] OR “dysrhythmia” [All Fields] OR
“fibrillation” [All field]
Intervention “transthoracic cardioversion of atrial fibrillation” [MeSH Terms] OR
“effectiveness of monophasic shock or biphasic shock” [All Field]
Comparison None
Outcome “Prevent dysrhythmia” [MeSH Terms] OR “prevent atrial fibrillation” [All
Field] OR “Patient retrieval” [All field] OR “patient retrieval” [All field] OR
“Well-being of patient” [All field] OR “well-being of patient” [All field]
APPENDIX B: Data extraction process
Criteria/Author Steven C Faddy,
Paul A Jennings,
2016
Aleksandr Voskoboinik
et. al., 2018
José Francisco Secorun
Inácio et. al., 2015
Random
sequence
formulation
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Is the
intervention and
control explicitly
illustrtated?
Does the
Randomized
Control Trial
presents an
intention to treat
the analysis?
Clinically
relevant results
Selection bias
Other risk of bias
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