Comparison of High vs. Escalating Shocks - CHESS

Aug 31, 2019
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Aarhus University and Randers Regional Hospital, Denmark.
Date Presented:
08/31/2019
Date Published:
08/31/2019
Original Posted Date:
08/31/2019
References

Contribution To Literature:

The CHESS trial showed that maximum-fixed dose shocks were superior at converting to normal sinus rhythm.

Description:

The goal of the trial was to evaluate maximum-fixed dose compared with low-escalating biphasic shocks among patients undergoing elective cardioversion for atrial fibrillation.

Study Design

  • Randomized
  • Parallel

Patients with atrial fibrillation undergoing cardioversion were randomized to maximum-fixed dose (360-360-360 J; n = 129) vs. low-escalating biphasic shocks (125-150-200 J; n = 147). Patients in each group could receive up to three shocks, if necessary, to achieve normal sinus rhythm.

  • Total number of enrollees: 276
  • Duration of follow-up: Hospitalization
  • Mean patient age: 68 years
  • Percentage female: 28%
  • Percentage with diabetes: 9%

Inclusion criteria:

  • Patients at least 18 years of age with atrial fibrillation undergoing elective cardioversion

Exclusion criteria:

  • Hemodynamically unstable atrial fibrillation
  • Untreated hyperthyroidism
  • Pregnancy
  • Previous enrollment in the study

Other salient features/characteristics:

  • In 30%, atrial fibrillation duration was >1 year

Principal Findings:

The primary outcome, sinus rhythm 1 minute after cardioversion, occurred in 88% of the maximum-fixed energy group vs. 66% of the low-escalating energy group (p < 0.001).

Secondary outcomes:

  • Sinus rhythm after first shock: 75% of the maximum-fixed energy group vs. 34% of the low-escalating energy group
  • Any arrhythmia, myocardial injury, skin burns, and patient-reported pain after cardioversion were similar between groups

Interpretation:

Among patients with atrial fibrillation undergoing elective cardioversion, maximum-fixed dose shocks were more effective at converting to normal sinus rhythm 1 minute after the procedure. Safety endpoints were similar between the groups. Larger studies with longer follow-up are needed to confirm if maximum-fixed dose shocks are the preferred strategy for conversion of atrial fibrillation to normal sinus rhythm.

References:

Schmidt AS, Lauridsen KG, Torp P, Bach LF, Rickers H, Løfgren B. Maximum-fixed energy shocks for cardioverting atrial fibrillation. Eur Heart J 2020;41:626-31.

Editorial: Klein HU. Elective DC cardioversion of atrial fibrillation: did we use the right procedure? Eur Heart J 2020;41:632-3.

Presented by Dr. Anders Sjørslev Schmidt at the European Society of Cardiology Congress, Paris, France, August 31, 2019.

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Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Prevention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: ESC Congress, ESC 19, Arrhythmias, Cardiac, Arrhythmia, Sinus, Atrial Fibrillation, Burns, Electric, Electric Countershock, Myocardium, Pain, Secondary Prevention, Shock


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