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

Background: To compare the acceptability and effectiveness of three pre-medication regimens for manually activated cardioversion of recurrent persistent atrial fibrillation. Methods: Eighteen patients implanted with the Jewel AF atrial defibrillator for drug-resistant persistent atrial fibrillation only were studied in an open-labelled randomised crossover study. Patients were assigned to sedation (S) with midazolam elixir, analgesia (A) with morphine sulphate or combination therapy (C) with dextromoramide and lorazepam. Pre-medication was taken up to 1 h before cardioversion. Patients rotated through each type of medication after undertaking at least one cardioversion. Visual analogue scales were completed immediately post-cardioversion and 24 h later for pain, anxiety and ‘unpleasantness’. Higher scores represented a worse outcome. Results: After 2 yearsʹ follow-up, 238 cardioversions were performed with S, 17 with A and 35 with C. The mean immediate combined score for S (10.9, 95% confidence interval (CI) 8.2–13.6) was significantly lower than for A (17.3, 95% CI 15.1–19.5, P=0.01) and for C (15.9, 95% CI 12.3–19.6, P=0.02). All patients who used S chose it as the most favourable pre-medicant. All patients who used A found it the least acceptable. Conclusion: Sedation rather than analgesia enhanced the acceptability of manually activated atrial defibrillation.