• M Scholten, T Szili-Torok, P Klootwijk, and L Jordaens.
• Erasmus University Medical Centre, Thoraxcentre, Department of Clinical Electrophysiology, Rotterdam, Netherlands. m.f.scholten@erasmusmc.nl
• Heart. 2003 Sep 1; 89 (9): 1032-4.

ObjectiveTo compare the efficacy of cardioversion in patients with atrial fibrillation between monophasic damped sine waveform and rectilinear biphasic waveform shocks at a high initial energy level and with a conventional paddle position.DesignProspective randomised study.Patients And Setting227 patients admitted for cardioversion of atrial fibrillation to a tertiary referral centre.Results70% of 109 patients treated with an initial 200 J monophasic shock were cardioverted to sinus rhythm, compared with 80% of 118 patients treated with an initial 120 J biphasic shock (NS). After the second shock (360 J monophasic or 200 J biphasic), 90% of the patients were in sinus rhythm in both groups. The mean cumulative energy used for successful cardioversion was 306 J for monophasic shocks and 159 J for biphasic shocks (p < 0.001).ConclusionsA protocol using monophasic waveform shocks in a 200-360 J sequence has the same efficacy (90%) as a protocol using rectilinear biphasic waveform shocks in a 120-200 J sequence. This equal efficacy is achieved with a significantly lower mean delivered energy level using the rectilinear biphasic shock waveform. The potential advantage of lower energy delivery for cardioversion of atrial fibrillation needs further study.

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