{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,27]],"date-time":"2026-06-27T23:13:58Z","timestamp":1782602038447,"version":"3.54.5"},"reference-count":25,"publisher":"Wiley","issue":"7","license":[{"start":{"date-parts":[[2014,8,12]],"date-time":"2014-08-12T00:00:00Z","timestamp":1407801600000},"content-version":"vor","delay-in-days":42,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Academic Emergency Medicine"],"published-print":{"date-parts":[[2014,7]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Objectives<\/jats:title><jats:p>Electrical cardioversion is commonly used to treat patients with atrial fibrillation and atrial flutter to restore normal sinus rhythm. There has been considerable debate as to whether the electrode placement affects the efficacy of electrical cardioversion. The objective of this study was to examine the effectiveness of anteroposterior (A\u2010P) versus anterolateral (A\u2010L) electrode placement to restore normal sinus rhythm.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>A search of eight electronic databases, including Medline, EMBASE, CINAHL, and Cochrane was completed. Grey literature (hand\u2010searching, Google, and SCOPUS) searching was also conducted. Studies were included if they were controlled clinical trials comparing the effectiveness of A\u2010P versus A\u2010L pad placement to restore normal sinus rhythm in adult patients with atrial fibrillation and flutter. Two independent reviewers judged study relevance, inclusion, and quality (e.g., risk of bias). Individual and pooled statistics were calculated as relative risks (RRs) with 95% confidence intervals (CIs) using a random\u2010effects model, and heterogeneity (I<jats:sup>2<\/jats:sup>) was reported.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>From 788 citations, 13 studies were included; seven involved monophasic, five involved biphasic, and one analyzed both waveform devices. The included studies tended to report cumulative success rates to restoring normal sinus rhythm after one to five sequential shocks of increasing energy; the number of shocks and energy used differed among studies. The risk of bias of the studies was \u201cunclear.\u201d After the first shock, pad placement was not associated with an increased likelihood of restoring normal sinus rhythm (RR = 0.88; 95% CI = 0.73 to 1.06); however, heterogeneity was high (I<jats:sup>2<\/jats:sup> = 63%). Subgroup comparisons revealed that the A\u2010L position was more effective (RR = 0.77; 95% CI = 0.59 to 1.00) at restoring normal sinus rhythm when using biphasic shocks (comparison p = 0.04). Overall, the pooled results failed to identify a difference between A\u2010P and A\u2010L pad placement in restoring normal sinus rhythm at any time (RR = 1.00; 95% CI = 0.95 to 1.05); however, heterogeneity was high (I<jats:sup>2<\/jats:sup> = 61%). No significant subgroup differences were found. Side effects were reported in only three studies.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>The published literature is restricted to persistent atrial fibrillation and atrial flutter, pad placement varied, and energy levels used were lower than currently recommended; however, the accumulated evidence suggests that electrical pad placement is not a critically important factor in successful cardioversion in atrial fibrillation and flutter (AF\/AFL). A trial is urgently needed in recent\u2010onset atrial fibrillation and atrial flutter patients using biphasic devices and high energy levels to resolve the debate.<\/jats:p><\/jats:sec>","DOI":"10.1111\/acem.12407","type":"journal-article","created":{"date-parts":[[2014,8,12]],"date-time":"2014-08-12T22:43:18Z","timestamp":1407883398000},"page":"717-726","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":37,"title":["The Efficacy of Pad Placement for Electrical Cardioversion of Atrial Fibrillation\/Flutter: A Systematic Review"],"prefix":"10.1111","volume":"21","author":[{"given":"Scott","family":"Kirkland","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine University of Alberta Edmonton Alberta Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ian","family":"Stiell","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine University of Ottawa Ottawa Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tariq","family":"AlShawabkeh","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine University of Alberta Edmonton Alberta Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sandy","family":"Campbell","sequence":"additional","affiliation":[{"name":"J. 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Scott Health Sciences Library University of Alberta Edmonton Alberta Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Garth","family":"Dickinson","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine University of Ottawa Ottawa Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian H.","family":"Rowe","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine University of Alberta Edmonton Alberta Canada"},{"name":"School of Public Health University of Alberta Edmonton Alberta Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2014,8,12]]},"reference":[{"key":"e_1_2_8_2_1","first-page":"9B","article-title":"2004 Canadian Cardiovascular Society consensus conference: atrial fibrillation","volume":"21","author":"Heilbron B","year":"2005","journal-title":"Can J Cardiol"},{"key":"e_1_2_8_3_1","first-page":"19A","article-title":"Management of supraventricular tachycardia in the emergency department","volume":"13","author":"Connors S","year":"1997","journal-title":"Can J Cardiol"},{"key":"e_1_2_8_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0196-0644(99)70300-8"},{"key":"e_1_2_8_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.annemergmed.2010.07.005"},{"key":"e_1_2_8_6_1","first-page":"38","article-title":"Canadian cardiovascular society atrial fibrillation guidelines 2010: management of recent\u2010onset atrial fibrillation and flutter in the emergency department","volume":"27","author":"Stiell IG","year":"2011","journal-title":"Ann Emerg Med"},{"key":"e_1_2_8_7_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.1962.03050440040012"},{"key":"e_1_2_8_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0735-1097(02)01898-3"},{"key":"e_1_2_8_9_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM198109173051202"},{"key":"e_1_2_8_10_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0167-5273(00)00326-0"},{"key":"e_1_2_8_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(02)11315-8"},{"key":"e_1_2_8_12_1","unstructured":"HigginsJP GreenS.Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. 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