Prediction of ineffective elective cardioversion of atrial fibrillation: a retrospective multi-center patient cohort study

BACKGROUND

Elective cardioversion (ECV) of atrial fibrillation (AF) is a standard procedure to restore sinus rhythm. However, predictors for ineffective ECV (failure of ECV or recurrence of AF within 30 days) are unknown.

METHODS

We investigated 1998 ECVs performed for AF lasting >48 h in 1,342 patients in a retrospective multi-center study. Follow-up data were collected from 30 days after ECV.

RESULTS

Median number of cardioversions was one per patient with a range of 1-10. Altogether 303/1998 (15.2%) ECVs failed. Long (>5 years) AF history and over 30 days duration of the index AF episode were independent predictors for ECV failure and low (<60/min) ventricular rate of AF predicted success of ECV. In patients with successful ECVs an early recurrence of AF was detected in 549 (32.4%) cases. Female gender, high (>60/min) ventricular rate, renal failure and antiarrhythmic agents at discharge were the independent predictors for recurrence. In total ECV was ineffective in 852 (42.6%) cases. Female gender (OR 1.44, CI95% 1.15-1.80, p < 0.01), young (<65 years) age (OR 1.31, CI95% 1.07-1.62, p = 0.01), ventricular rate >60/min (OR 1.92, CI95% 1.08-3.41, p = 0.03), antiarrhythmic medication at discharge (OR 1.48, CI95% 1.14-1.93, p < 0.01) and low (<60/ml/min) estimated glomerular filtration rate (OR 1.59, CI95% 1.08-2.33, p = 0.02) were predictors of ineffective ECV.

CONCLUSIONS

Female gender, use of antiarrhythmic drug therapy and renal failure predicted both recurrence of AF and the composite end point. For the first time in a large real-life study several clinical predictors for clinically ineffective ECV were identified.

Tool design, user characteristics and performance: a case study on plate-shears

Performance, grip forces and fatigue were studied in six male and six female subjects while cutting with plate-shears. Three types of plate-shears were used, one standard and two modified, either with a spring grip, or with a spring grip in combination with a reduced grip span. In addition, three types of plate - easy, moderately difficult and difficult to cut - were used. Male subjects used around 40% of their maximal grip force and female subjects around 60% with the moderately difficult plate; the male subjects produced more than twice as long a cutting distance as the females. Neither EMG analysis (frequency shifts) nor subjective exertion or reduction of handgrip MVC indicated a more pronounced fatigue in women than in men, probably because the female subjects used about a 50% lower cutting rate than the men. Productivity (in cm cut per min) was strongly related to measures of hand size and to the relative grip force used. Thus in a multiple regression analysis using metacarpal hand circumference and relative grip force as independent variables, R2 was 0.77. The two types of modified plate-shears were preferred by all and gave a roughly 30% higher productivity in the male subjects but did not improve productivity in the females. However, with a spring grip and reduced grip span, the female subjects reduced the relative grip forced used from around 65 to 50%. The total work (force-time integral) per cm cut was not influenced by type of plate-shear.