Improving the acceptability of the atrial defibrillator for the treatment of persistent atrial fibrillation: the atrial defibrillator sedation assessment study (ADSAS)

Mitchell, Andrew R.J.; Spurrell, Philip A.R.; Gerritse, Bart; Sulke, Neil

doi:10.1016/j.ijcard.2003.04.060

Cited by 16 publications

(14 citation statements)

References 23 publications

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“…Oral benzodiazepines are generally safe for ambulatory use but have limited effectiveness reducing shock pain/discomfort. For example, oral midazolam (15 mg) modestly reduced ICD‐AT associated baseline pain and unpleasantness by 25% while not affecting anxiety 14 . In the current study, N 2 O therapy reduced shock related pain/discomfort by a greater magnitude than oral sedation but is less effective than intravenous sedation 15 .…”

Section: Discussionmentioning

confidence: 46%

Nitrous Oxide Sedation Reduces Discomfort Caused by Atrial Defibrillation Shocks

Ujhelyi

Hoyt

Burns

et al. 2004

Pacing Clinical Electrophis

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An implantable cardioverter defibrillator with atrial therapies (ICD-ATs) is an effective therapy to manage atrial tacharrhythmias. Acceptance of this therapy is limited by atrial shock related anxiety and discomfort. Inhaled nitrous oxide (N2O) is a potent sedative-analgesic-anxiolytic agent that may mitigate shock discomfort and anxiety and improve patient ICD-AT acceptance. ICD-AT patients with more than one ambulatory atrial shock within 12 months were enrolled and grouped by ICD-AT shock method; awake (n = 9) or asleep (n = 4) when ambulatory ICD-AT shock is delivered. A baseline questionnaire assessed the most recent ambulatory ICD-AT shock (3 +/- 3 months). A 65% N2O/35% O2 mixture was inhaled for 4 minutes followed by an ICD-AT test shock (18 +/- 8 J). The test shock mimicked the awake shock method. The test shock experience during N2O was evaluated via questionnaire immediately following and 24 hours after the shock. Shock related anxiety, intensity, pain, and discomfort were assessed using a ten-point rank scale. Baseline test shock scores were similar between the shock method groups. In the awake shock method group, N2O greatly reduced preshock anxiety by 48% (6.4 +/- 2.4 to 3.3 +/- 2.0, or), and shock related intensity (5.9 +/- 3.1 to 3.3 +/- 2.5), pain (5.0 +/- 2.6 to 2.0 +/- 2.1), and discomfort (5.6 +/- 2.4 to 1.3 +/- 1.4) from baseline values by 45%, 60%, and 78% (P < 0.05), respectively. The asleep shock method group reported no changes in shock related anxiety, intensity, pain, or discomfort. Atrial shock concern, assessed via a five-point rank scale (5 = extreme concern) was improved by N2O but only in the awake group (3.1 +/- 1.0 baseline to 1.6 +/- 0.5 N2O, P = 0.008). There were no adverse events with N2O and patients fully recovered within 5 minutes after N2O. In conclusion, 65% N2O greatly reduced shock related pain and discomfort, and significantly reduced atrial shock concern but only in the awake shock method group. The benefits of N2O therapy may expand the use and acceptability of ICD-AT therapy into a larger atrial fibrillation cohort.

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Section: Discussionmentioning

confidence: 46%

Nitrous Oxide Sedation Reduces Discomfort Caused by Atrial Defibrillation Shocks

Ujhelyi

Hoyt

Burns

et al. 2004

Pacing Clinical Electrophis

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“…The second approach allows very low energies (no more than 3 or 4 J) to be used for conversion of AF. Devices of this type have been extensively evaluated (Table I) in patients with both atrial and ventricular tachyarrhythmias, and have also been implanted in a few selected “AF‐only” patients 21–23,26–41 …”

Section: Knowledge Derived From Available Reports Of Experiences Withmentioning

confidence: 99%

“…The discomfort is affected by many factors relating to individual characteristics, clinical and arrhythmic profile, shock characteristics, delivery modality, and concurrent treatments 11,15,43 . These factors have emerged from experiences both with internal atrial cardioversion 1,3,4 and implantable devices 10,27–29,39 . Moreover, perception of shock‐induced pain varies considerably from patient to patient 4 …”

Section: The Issue Of Shock‐induced Discomfortmentioning

confidence: 99%

How, Why, and When May Atrial Defibrillation Find a Specific Role in Implantable Devices? A Clinical Viewpoint

Boriani¹,

Diemberger²,

Biffi³

et al. 2007

Pacing Clinical Electrophis

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This viewpoint article discusses the potential for incorporation of atrial defibrillation capabilities in modern multi-chamber devices. In the late 1990s, the possibility of using shock-only therapy to treat selected patients with recurrent atrial fibrillation (AF) was explored in the context of the stand-alone atrial defibrillator. The failure of this strategy can be attributed to the technical limitations of the stand-alone device, low tolerance of atrial shocks, difficulties in patient selection, a lack of predictive knowledge about the evolution of AF, and, last but not least, commercial considerations. An open question is how atrial defibrillation capability may now assume a specific new role in devices implanted for sudden death prevention or cardiac resynchronization. For patients who already have indications for implantable devices, device-based atrial defibrillation appears attractive as a "backup" option for managing AF when preventive pharmacological/electrical measures fail. This and several other personalized hybrid therapeutic approaches await exploration, though assessment of their efficacy is methodologically challenging. Achievement of acceptance by patients is an essential premise for any updated atrial defibrillation strategy. Strategies that are being investigated to improve patient tolerance include waveform shaping, pharmacologic modulation of pain, and patient-activated defibrillation (patients might also perceive the problem of discomfort somewhat differently in the context of a backup therapy). The economic impact of implementing atrial defibrillation features in available devices is progressively decreasing, and financial feasibility need not be a major issue. Future studies should examine clinically relevant outcomes and not be limited (as occurred with stand-alone defibrillators) to technical or other soft endpoints.

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“…The atrial defibrillator sedation assessment study (ADSAS) assessed the pain tolerance for patients receiving atrial defibrillation shocks from an implanted ICD when pre-medicated. 35 Patients were given oral medication prior to receiving defibrillation shocks for sedation (midazolam elixir), analgesia (morphine sulphate), or combination sedation and analgesia therapy. Patients preferred the sedation option to the other two treatment options, but still described shocks as painful.…”

Section: Patient Control Through Sedation or Nighttime Shocksmentioning

confidence: 99%

Intracardiac atrial defibrillation

Dosdall

Ideker

2007

Heart Rhythm

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Intravascular ventricular defibrillation and intravascular atrial defibrillation have many similarities, some of which are as follows. An important factor influencing the outcome of the shock is the potential gradient field created throughout the ventricles or the atria by the shock. A minimum potential gradient is required throughout the ventricles and probably the atria to defibrillate. The value of this minimum potential gradient is affected by several factors including the duration, tilt, and number of phases of the waveform. For shock strengths near the defibrillation threshold, earliest activation following failed shocks arises in a region in which the potential gradient is low. The defibrillation threshold energy can be decreased by adding a third and even a fourth defibrillation electrode in regions where the shock potential gradient is low for the shock field created by the first two defibrillation electrodes and giving two sequential shocks, each through a different set of electrodes. However, the addition of more electrodes and sequential shocks complicates both the device and its implantation.Since patients are conscious when the atrial defibrillation shock is given, they experience pain during the shock, which is one of the main drawbacks of intravascular atrial defibrillation. Unfortunately, the pain threshold for defibrillation shocks is so low that a shock of less than 1 Joule is uncomfortable and is not much less painful than shocks several times stronger. Therefore, even though electrode configurations exist that have lower atrial defibrillation threshold energy requirements than the atrial defibrillation threshold with standard defibrillation electrode configurations used in implantable cardioverter/defibrillators (ICDs) for ventricular defibrillation, they are not clinically practical because their shocks are almost as painful as with the standard ICD electrode configurations and they would cause the ICD to be more complicated and to take longer and be more difficult to implant.

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Improving the acceptability of the atrial defibrillator for the treatment of persistent atrial fibrillation: the atrial defibrillator sedation assessment study (ADSAS)

Cited by 16 publications

References 23 publications

Nitrous Oxide Sedation Reduces Discomfort Caused by Atrial Defibrillation Shocks

Nitrous Oxide Sedation Reduces Discomfort Caused by Atrial Defibrillation Shocks

How, Why, and When May Atrial Defibrillation Find a Specific Role in Implantable Devices? A Clinical Viewpoint

Intracardiac atrial defibrillation

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