Post-shock myocardial stunning: A prospective randomised double-blind comparison of monophasic and biphasic waveforms

SummaryIntroductionCompared with monophasic defibrillation, biphasic defibrillation is associated with less myocardial stunning and earlier activation of sodium channels. We therefore hypothesised that earlier sodium channel activation would result in earlier restoration of the first sinus beat following elective DC cardioversion.MethodsAdults undergoing elective DC cardioversion were randomised to receive either monophasic or biphasic escalating transthoracic shocks. The ECG was recorded electronically during defibrillation and the time from delivery of the shock to restoration of the first sinus beat, measured from the beginning of the ‘P’ wave, was calculated.ResultsSeventy four patients were studied. Data were unavailable from 18 patients. There was no demographic difference between groups. Median time to the first sinus beat following monophasic defibrillation (n = 25) was 3.66 s (95% CI 2.55–4.61 s) and following biphasic defibrillation (n = 33) was 2.21 s (95% CI 1.76–2.56 s; P ≤ 0.0001). Linear regression confirmed that the waveform was an independent predictor of time to restoration of sinus rhythm; P < 0.0001. The final defibrillation energy level used to achieve cardioversion was not an independent predictor of time to restoration of sinus rhythm; P = 0.49.ConclusionBiphasic defibrillation for elective DC cardioversion achieved more rapid restoration of the first sinus beat compared with a monophasic waveform. Waveform, but not energy level that achieved defibrillation, was an independent predictor of time to restoration of the first sinus beat. The mechanism for this may be related to the earlier reactivation of sodium channels associated with the biphasic waveform.