title: Plateau waveform shape allows a much higher patient shock energy tolerance in AF patients.
abstract: OBJECTIVE
  To evaluate the possible pain reduction of the plateau waveform in atrial fibrillation (AF) patients.
  
  
  BACKGROUND
  Previous studies have indicated that reduced amplitude waveforms would be less painful than a conventional (65/65% tilt) biphasic waveform. Computer modeling suggested that a moderately long (10-12 msec) plateau (flat topped) shock waveform would deliver equivalent effectiveness with the lowest possible peak amplitude.
  
  
  METHODS
  We enrolled 27 patients at two sites with persistent AF with a total of 220 shocks delivered during internal atrial cardioversion using an interleaved crossover design. Patient response was scored in three ways: (1) a verbally reported discomfort score, (2) visual analog scale (VAS), and (3) a blinded observer reporting a contraction score.
  
  
  RESULTS
  All scores were significantly reduced (P < 0.0001) by the plateau waveform with impressive statistics: Verbal discomfort (3.51 +/- 0.13 to 2.89 +/- 0.12), VAS (7.00 +/- 0.56 to 5.91 +/- 0.36), and contraction scores (1.94 +/- 0.12 to 1.62 +/- 0.12). The average pain threshold shift (TS) for the Verbal score was 2.34, while that for the VAS score was 2.30. (This means that the patient typically could tolerate 2.34 times as much energy with the plateau waveform for the same level of verbally reported discomfort.) The contraction TS was less at 1.57. Response scores were also corrected for the shock sequence number to control for the sensitization effect from multiple shocks. This increased the TS for the Verbal score to 3.58, but the shock number was not significant for the VAS. A pulmonary artery electrode return was associated with lower pain compared with a coronary sinus position.
  
  
  CONCLUSIONS
  A plateau shaped biphasic waveform resulted in significantly increased shock energy pain tolerances. Controlling for session sensitization, patients tolerated over three times as much energy for the same verbally reported discomfort score.
authors.affiliation: Institute of Cardiology, University of Bologna, Az. Osp. S. Orsola-Malpighi, Bologna, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Boriani
authors.forename: Nils
authors.initials: N
authors.lastname: Edvardsson
authors.forename: Mauro
authors.initials: M
authors.lastname: Biffi
authors.forename: Paolo
authors.initials: P
authors.lastname: Silvestri
authors.forename: Cristian
authors.initials: C
authors.lastname: Martignani
authors.forename: Cinzia
authors.initials: C
authors.lastname: Valzania
authors.forename: Igor
authors.initials: I
authors.lastname: Diemberger
authors.forename: J Christopher
authors.initials: JC
authors.lastname: Moulder
authors.forename: Gabriel
authors.initials: G
authors.lastname: Mouchawar
authors.forename: Dritan
authors.initials: D
authors.lastname: Poci
authors.forename: Angelo
authors.initials: A
authors.lastname: Branzi
authors.forename: Mark W
authors.initials: MW
authors.lastname: Kroll
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000503:physiopathology* / Q000628:therapy*; D018592:Cross-Over Studies; D004554:Electric Countershock / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement / Q000379:methods; D011237:Predictive Value of Tests