Transthoracic Cardioversion: Monophasic vs Biphasic Shock Efficacy

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Literature Review
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This literature review examines the efficacy of monophasic versus biphasic shocks for transthoracic cardioversion of atrial fibrillation. The review analyzes studies sourced from databases like Cochrane Library, PubMed, and EMBASE up to July 20, 2022, focusing on randomized controlled trials and observational studies. The primary outcomes assessed are the termination of atrial fibrillation using monophasic and biphasic shocks, with secondary outcomes including cardiac death and vascular complications. The review includes a PICO framework for study selection, quality assessment using established criteria, and statistical analysis to compare the effectiveness of the two shock types. The results indicate that biphasic shocks are generally more effective for defibrillation success, minimizing heart exposure to high current and improving treatment outcomes compared to monophasic shocks, which may increase cellular injury and side effects. The review concludes that biphasic shocks are preferred for cardioversion due to their higher success rate in defibrillation.
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Comparison between efficacy of
monophasic vs biphasic shocks for
transthoracic cardioversion of atrial
fibrillation
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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
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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
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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
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LIST OF ABBREVIATIONS
AF Atrial fibrillation
EC Electrical cardioversion
RCT Randomized Control Trial
I ampere
OHCA Oklahoma Health Care Authority
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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.
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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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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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