TOPLINE:

A new study showed that cardioversion of recent-onset atrial fibrillation (AF) or flutter in the emergency department (ED) was safe and highly effective in patients with class III or IV obesity, with a 92.3% success rate and no adverse airway events.

METHODOLOGY:

• Researchers conducted a retrospective chart review of 78 patients with severe obesity (class III, BMI ≥ 35 to < 40 or class IV, BMI ≥ 40; mean BMI, 39.9; 51% men) who underwent direct current cardioversion (DCCV) for recent-onset AF (88.5%) or flutter (10.3%) in a single urban ED between 2023 and 2025.
• Cardioversion shocks were delivered using anterior-posterior adhesive pads under procedural sedation.
• Procedural variables included blood pressure measurements, continuous nasal capnometry, cardiac monitoring, sedation medications, oxygen delivery methods, pulse oximetry, and standard airway interventions.
• The outcomes were successful DCCV, defined as a change in rhythm from AF to sustained normal sinus rhythm; adverse events associated with procedural sedation, including endotracheal intubation or hypotension (systolic blood pressure [SBP] < 90 mm Hg); and patient disposition.

TAKEAWAY:

• DCCV was successful in 92.3% of patients (80.8% on the first attempt), and the success rate did not vary by patient weight or BMI.
• No adverse airway events were recorded; however, 14% of patients experienced transient hypotension, with presedation blood pressure of 113.5 mm Hg in those patients experiencing hypotension vs 134.6 mm Hg in those without hypotension. Around 5.1% required a period of bag-valve-mask ventilation.
• Hypotension occurred only in patients who received propofol and was more common with lower doses (mean, 0.51 mg/kg) than with higher doses (mean, 0.71 mg/kg). None of the patients required vasoactive medications or experienced adverse cardiovascular or neurologic events.
• Overall, 74.5% of patients were discharged from the ED, including 78.3% with AF and 44.4% with atrial flutter, and all patients' SBP returned to baseline values prior to disposition.

IN PRACTICE:

"This is the first study to describe Emergency Physician's ability to [manage] both the procedural sedation and electrical cardioversion of class III and class IV obese patients," the authors wrote. "The use of DCCV [for] recent-onset AF in obese patients is both safe and effective when performed in the ED setting," they added.

SOURCE:

The study was led by Alfred Sacchetti, MD, Virtua Our Lady of Lourdes Hospital, Camden, New Jersey. It was published online on August 12, 2025, in The American Journal of Emergency Medicine.

LIMITATIONS:

The study's single-center, retrospective design may have limited the generalizability of the findings, and variations in emergency physicians' practice patterns may have affected outcomes. The relatively small sample size of patients with severe obesity may have reduced the study's statistical power.

DISCLOSURES:

No funding source was reported for the study, and the authors reported having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.