{"id":"74d7315c9300","type":"article","url":"https://hartvaat.nl/2026/02/04/200-joule-als-startenergie-voor-elektrische-cardioversie-bij-atriumfibrilleren-w/","title":"200 joule als startenergie voor elektrische cardioversie bij atriumfibrilleren werkt goed en veilig","title_en":"200 J-first, fixed-escalation biphasic electrical cardioversion for atrial fibrillation >48 hours in the emergency department: a single-centre retrospective observational study","category":"algemeen","category_label":"Algemeen","professions":["cardioloog"],"tags":["farmaco-economie","ouderen"],"journal":"Open Heart","doi":"http://openheart.bmj.com/cgi/content/short/13/1/e003875?rss=1","source_url":"https://doi.org/http://openheart.bmj.com/cgi/content/short/13/1/e003875?rss=1","authors":["Nozewski","J.","Siudak","Z.","Backus","B. E.","Exadaktylos","A."],"significance":5,"published":"2026-02-04","source_date":"2026-02-04","image":"","kennis":["https://hartvaat.nl/kennis/coronairlijden/esc-richtlijn-chronisch-coronairlijden-2024/","https://hartvaat.nl/kennis/antistolling/doacs-overzicht/"],"congress":"","summary_en":"In electrical cardioversion (ECV) of atrial fibrillation (AF) lasting more than 48 hours, up to 360 joules is permitted; the CHESS trial found higher success with a fixed 360J start. In this retrospective single-centre study (374 elective ECVs in the emergency department, 2019-2021), a fixed escalating sequence of 200→300→360 J was used with a standardised technique (hand-held paddles, firm pressure, anterolateral placement under deep sedation). Sinus rhythm was restored in 97.3%; the first 200 J shock succeeded in 88.0%. Only 44 and 15 patients needed 300 J and 360 J respectively. There were two minor adverse events (0.5%) and none serious. A 200J-first protocol with standardised technique thus gives high first-shock and excellent cumulative success in long-standing AF, without routine pharmacological adjuncts.","created":"2026-07-03T10:32:26Z","updated":"2026-07-03T18:39:25Z","licence":"Citeer vrij, met bronvermelding en een link naar hartvaat.nl (de url van het record). Samenvattingen zijn redactioneel werk van HartVaat; de oorspronkelijke publicaties blijven van hun uitgevers (doi). Geen medisch advies.","body_markdown":"Bij elektrische cardioversie (ECV) van atriumfibrilleren (AF) dat langer dan 48 uur bestaat, mag tot 360 joule worden gebruikt; de CHESS-trial vond een hogere succeskans met een vaste 360J-start. In deze retrospectieve single-centerstudie (374 electieve ECV's op de spoedeisende hulp, 2019-2021) werd een vaste oplopende reeks van 200→300→360 J gehanteerd, met een gestandaardiseerde techniek (handpaddles, stevige druk, anterolaterale plaatsing onder diepe sedatie). Sinusritme werd hersteld bij 97,3%; de eerste schok van 200 J was succesvol bij 88,0%. Slechts 44 en 15 patiënten hadden 300 J respectievelijk 360 J nodig. Er waren twee kleine bijwerkingen (0,5%) en geen ernstige. Een 200J-startprotocol met gestandaardiseerde techniek geeft dus een hoge eerste-schok- en uitstekende cumulatieve succeskans bij langdurig AF, zonder routinematige medicamenteuze ondersteuning.","abstract_original":"<sec><st>Background</st>\n<p>Guidelines permit up to 360 J for synchronised biphasic electrical cardioversion (ECV) in atrial fibrillation (AF) lasting &gt;48 hours. The CHESS randomised trial reported higher first-shock success with fixed 360J versus a low-escalation 125&ndash;150&ndash;200J sequence. Much of this evidence used adhesive pads without manual pressure and anterior&ndash;posterior positioning. We evaluated a 200 J-first, fixed-escalation biphasic ECV protocol delivered with a standardised technique in an emergency department (ED).</p>\n</sec>\n<sec><st>Methods</st>\n<p>Single-centre retrospective observational study of consecutive adults undergoing elective ECV for symptomatic AF &gt;48hours (2019&ndash;2021). Procedures used hand-held paddles with firm chest pressure in the anterolateral (AL) position under deep sedation. The predefined sequence was 200-&gt;300-&gt;360J if needed. The primary outcome was restoration of sinus rhythm (SR) documented on a 12-lead ECG within 120 min. Secondary outcomes were first shock success at 200 J, cumulative efficacy, SR to discharge without post-ECV antiarrhythmics, adverse events and subgroup efficacy. Results were contrasted descriptively with 360 J-first cohorts (CHESS).</p>\n</sec>\n<sec><st>Results</st>\n<p>Of 451 ECV procedures identified, 374 were eligible. The primary outcome was achieved in 97.3% (364/374; 95% CI 95.5 to 98.7). First-shock success with 200 J was 88.0% (329/374; 95% CI 84.3 to 90.9). Escalation to 300 J and 360 J was required in 44 and 15 patients. SR was maintained to discharge in converted patients. Two minor adverse events occurred (2/374, 0.5%) and no serious adverse events were recorded.</p>\n</sec>\n<sec><st>Conclusions</st>\n<p>A 200 J-first, fixed-escalation biphasic protocol with a standardised technique (manual paddles, firm pressure, AL placement) achieved high first-shock and excellent cumulative efficacy for AF&gt;48 hours in real-world ED care without routine pharmacologic adjuncts. Findings support considering a 200 J-first approach and motivate pragmatic multicentre randomised controlled trials directly comparing 200 J-first versus 360 J-first under harmonised technique with objective safety endpoints.</p>\n</sec>"}