Table 2
Author, date and countryPatient groupStudy type (level of evidence)OutcomesKey resultsStudy weaknesses
Mathew TP et al, 1999, UK90 patientsProspective, randomisedCardioversion success rate38/45 success for AL v 33/45 for AP p = 0.42.No power
ElectiveMean (SD) energy used223 (96.1) J for AL v 232 (110) J for APRandomisation method not explicit
Antero-lateral (AL) v Antero-posterior (AP)Mean (SD) thoracic impedance on first shock77.5 (18.4) Ohms AL v 73.7 (18.7) Ohms AP p = 0.34Elective patients
100J then 200J, 300J, 360J
Botto GL et al, 1999, Italy301 patients with stable AFProspective randomised controlled trialSuccess rate at initial 3J/kg shock87/151 success for AL v 100/150 for AP.No power calculation
AL v APCumulative success rate after first 4J/kg shock114/151 for AL v 131/150 for AP (p = 0.013)Randomisation method not explicit
3J/kg then 4J/kg then 4J/kg in alternative positionCumulative success after second 4J/kg shock140/150 for AL v 140/150 for AP p = NSAll elective with chronic AF
Alp NJ et al, 2000, UK59 patients with persistent AFRCT cross-overCardioversion success rate on first 360J DC shock.With first 360J AL more successful 18/30 v10/29 for AP (p = 0.048).Small numbers
AP v AL (360 J)Cardioversion second 360J shock4/19 for AL v 5/12 for AP p = 0.22Elective
Patients with persistent AF
Kirchhof P et al, 2002, Germany108 patients with persistent AFRCT cross-over (if no response in initial paddle position at 360J)Cardioversion success rate in initial paddle positions50/52 for AP v 44/56 for AL p = 0.009.Elective patients with persistent AF
Elective cardioversion (50–360J) AP v ALCardioversion if initial position failed8/12 cardioverted when crossed from AL to AP. No success in those AP to AL (2 patients)
Chen CJ and Guo GB, 2003, Japan70 patients with persistent AF (>1 month).Randomised controlled trialCardioversion success at 100JAP v AL 23% v19.4% p = NSSmall, low powered study
AL (31 patients) v AP (39 patients)Cumulative cardioversion success at 150JAP v AL 41% v 45.2% p = NSOnly looks at those with persistent AF in an elective setting (excluded those with new onset AF, one month)
Step up protocol 100, 150, 200, 300, 360 joulesCumulative cardioversion success at 200JAP v AL 66.7% v 74.2% p = NSNo randomisation details
Cumulative cardioversion success at 300JAP v AL 79.5% v 77.4% p = NS
Cumulative cardioversion success at 360JAP v AL 84.6% v 83.9% p = NS