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 Table of Contents  
Year : 2016  |  Volume : 1  |  Issue : 1  |  Page : 38-42

Feasibility of an Elective Cardioversion Service Led by Advanced Practice Providers without Direct Cardiologist Supervision

1 Division of Cardiology, Regions Hospital, St. Paul; HealthPartners Medical Group, Bloomington, Minnesota, USA
2 Division of Cardiology, Regions Hospital, St. Paul; HealthPartners Medical Group, Bloomington; University of Minnesota Medical School, St. Paul, Minnesota, USA
3 HealthPartners Medical Group, Bloomington; Division of Hospital Medicine, Regions Hospital, St. Paul, Minnesota, USA
4 Cardiac Arrhythmia and Syncope Center, University of Minnesota Medical School, Minneapolis, Minnesota, USA

Date of Web Publication30-Sep-2016

Correspondence Address:
Dennis W.X Zhu
Mail Stop 11102H, 640 Jackson Street, St. Paul, MN 55101
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2352-4197.191480

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Background: Elective direct current cardioversion (DCCV) has traditionally been performed by physicians in the United States. A few recent reports from the United Kingdom suggested that a specialist nurse-led service for elective DCCV of persistent atrial fibrillation was feasible. This practice has not been reported in the United States previously. Several years ago, we introduced a program where specially trained advanced practice providers (APPs) (physician assistants and nurse practitioners) assisted by an anesthesiology team, performed elective DCCV in patients with atrial fibrillation and atrial flutter, without direct cardiologist supervision. Methods: Upon receiving approval from the Institutional Review Board, we conducted a retrospective analysis of 447 consecutive DCCVs electively performed by APPs, for atrial fibrillation or atrial flutter, at Regions Hospital between 12/2006 and 10/2010. Transient deep sedation was administered by an anesthesiology team. The cohort was evaluated for procedural success and safety. Results: The procedural success rate was 92% (412/447). The incidence of procedural related adverse events, requiring immediate intervention, was 0.2% (1/447). This patient required emergent temporary pacing catheter insertion followed by a permanent pacemaker implantation at a later date. There were no other procedure-related complications and no thromboembolic events. A comparison with fifty elective cardioversions performed by cardiologists during the same period found no statistical difference in procedural success rates or complications. Conclusion: Under deep sedation administered by anesthesiology service, elective DCCV of atrial fibrillation and atrial flutter performed by well-trained APPs, without direct cardiologist supervision, is feasible and does not compromise patient safety.

Keywords: Atrial fibrillation, atrial flutter, electric countershock, nurse practitioner, physician assistant

How to cite this article:
House CM, Zhu DW, Saha MK, Hamieh TS, Benditt DG, Nelson WB. Feasibility of an Elective Cardioversion Service Led by Advanced Practice Providers without Direct Cardiologist Supervision. Int J Heart Rhythm 2016;1:38-42

How to cite this URL:
House CM, Zhu DW, Saha MK, Hamieh TS, Benditt DG, Nelson WB. Feasibility of an Elective Cardioversion Service Led by Advanced Practice Providers without Direct Cardiologist Supervision. Int J Heart Rhythm [serial online] 2016 [cited 2023 Jun 5];1:38-42. Available from: https://www.ijhronline.org/text.asp?2016/1/1/38/191480

  Introduction Top

The restoration of sinus rhythm is often desirable in the management of atrial fibrillation or atrial flutter and is frequently achieved by direct current cardioversion (DCCV). DCCV is a relatively safe procedure, with the most recognized complications being arrhythmias and thromboembolic events.[1],[2],[3],[4],[5]

Elective DCCV has traditionally been performed by cardiologists or other specially trained physicians in the United States. An aging population has led to a higher incidence of atrial fibrillation and an increasing demand of physician service. Given increasingly limited health-care resources, there is a need to find ways to improve the efficiency of cardiology practice without compromising the quality of patient care.[6] In particular, a recent document issued by the Center for Medicare Service (CMS) requiring that deep sedation not be administered by the same physician who also performed the procedure has demanded the involvement of two physicians for a simple elective DCCV procedure, which may further stress the cardiologist's workload.[7]

The expansion of clinical duties for advanced practice providers (APPs) (physician assistant and nurse practitioner, APP) has provided a potential alternative for enhancing the efficiency of physician practice.[8],[9] In regard to DCCV, there are several studies from the United Kingdom reporting the safety and effectiveness of a nurse specialist-led DCCV service, without direct physician supervision.[10],[11],[12] In these publications, the rate of restoring sinus rhythm ranged from 84% to 92%, with only infrequent, minor adverse events comparable to the outcome of DCCV performed by cardiologists.[13],[14],[15]

At our institution, APPs with special training in cardiology have performed the majority of the elective DCCV in patients with atrial fibrillation or atrial flutter over the last several years. The aim of this study was to analyze the outcome of patients whose elective DCCV was performed by an APP.

  Methods Top

Upon approval from the Institutional Review Board, a retrospective chart review of individuals undergoing elective DCCV for atrial fibrillation and atrial flutter was conducted at Regions Hospital, a major teaching affiliate of the University of Minnesota Medical School. Using an electronic medical record database (EPIC, Madison, Wisconsin, USA), we identified 447 consecutive DCCVs performed electively by APPs between 12/2006 and 10/2010. Patients were referred for cardioversion by their primary care physicians or cardiologists. After consent was acquired, DCCV was usually performed in the outpatient care unit or cardiac ward equipped with monitoring and resuscitation capabilities. Under transient intravenous deep sedation, administered by the anesthesiology service, elective DCCV was performed by an APP. No patients were selected or deemed unsuitable to proceed solely on the basis of the health-care professional performing the procedure.

Procedural success was defined as the restoration and maintenance of sinus rhythm at the end of the 1 h postprocedure observation period. Procedural success also included occasional patients whose atrial fibrillation or atrial flutter was converted to a stable junctional rhythm. A complication was defined as any adverse event that required intervention during the postprocedure observation period.

Advanced practice provider training requirements

Prior to performing elective DCCV without direct cardiologist oversight, all APPs satisfied the training requirements set forth by the department of cardiology at Regions Hospital. These requirements are listed as follows:(1) Be a board certified physician assistant or nurse practitioner, (2) have at least 1 year working experience in clinical cardiology and 6 months working experience in cardiac electrophysiology, with proficiency in arrhythmia interpretation, (3) have performed a minimum of 25 elective cardioversions supervised directly by a cardiologist, (4) current certification in advanced cardiac life support, and (5) demonstrate thorough understanding of the recent guidelines, especially the indications and contraindications for DCCV.[16] Of note, these requirements exceed the recommendation of eight supervised procedures for achieving DCCV competence in the ACP/ACC/AHA task force statement on clinical competence in elective DCCV.[16]

Direct current cardioversion procedure

Prior to the procedure, all patients were kept in a fasting state for at least 6 h. Patients were taking warfarin with an international normalized ratio ≥2.0 for at least 21 days prior to DCCV. If the duration of adequate anticoagulation was <21 days, the same day negative transesophageal echocardiography was mandatory to verify the absence of left atrial thrombus. Clinical and laboratory data were evaluated on the day of cardioversion. Current medications were documented. A focused physical examination incorporating vital signs, auscultation of the heart and lungs, and airway evaluation was performed. After signed informed consent was obtained, the defibrillation adhesive pads were applied in an anterior/posterior position; modification of pads was permitted according to operator's preference.

Transient deep sedation was administered by the anesthesiology service with intravenous methohexital sodium, etomidate, or diprivan. All cardioversions were performed using biphasic DC defibrillators (Zoll Medical, Boston, USA or Physio-Control, Redmond, USA). These contemporary devices were also capable of providing reliable transcutaneous pacing if needed. All cardioversions were R-wave synchronized with energy levels being protocol guided in accordance with AHA/ACC and ESC guidelines.[2] For atrial fibrillation, a regimen of 150, 200, and 200 J was used. For atrial flutter, 50, 100, and 200 J were applied. Energy level adjustment was allowed based on individual patient's weight, body habitus, and operator's preference. A higher energy level up to 360 J was at times applied (Physio-Control, Redmond, USA) when lower energy levels failed to convert atrial fibrillation. If clinically indicated, DCCV was repeated after intravenous infusion of 1 mg of ibutilide.[17] Continuous rhythm monitoring was used throughout the procedure. In the rare event of transient asystole or severe bradycardia after cardioversion, temporary transcutaneous pacing via the external defibrillator was usually sufficient. If bradycardia persisted in spite of intravenous atropine or epinephrine administration, a temporary transvenous pacing catheter would be inserted urgently in the cardiac catheterization laboratory by a cardiologist. The complications of deep sedation and airway issues were handled by the anesthesiology service. All patients were observed for a minimum of 1 h after completion of DCCV. The observation period was extended to 4 h if ibutilide was administered. The decision to discharge was made by the APP who performed the cardioversion. In addition to continuous rhythm monitoring, a 12-lead electrocardiogram was performed prior to discharge.

Statistical analysis

Continuous variables are expressed as a mean ± one standard deviation. The remaining variables are expressed as percentages. Continuous variables were compared using an unpaired t-test, with a P value of 0.05 indicative of a statistically significant difference. The incidence of dichotomous variables was compared using Fischer's exact test. Statistical analyses were performed using GraphPad Software, La Jolla, California, USA

  Results Top

There were 447 elective cardioversions performed by APPs in 391 patients. Of the 391 patients, 47 had repeat cardioversion attempts during the study period. The clinical characteristics for the patients and the outcome of DCCV are presented in [Table 1]. Of the 447 cardioversions, 412 successfully restored sinus rhythm, resulting in a procedural success rate of 92%. As expected, patients who failed DCCV had significantly more cardioversion attempts and received significantly higher energy levels than those who had successful DCCV [Table 2].
Table 1: Patient characteristics and procedure outcomes

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Table 2: Comparison of successful versus unsuccessful cardioversions

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Adverse events were rare and generally bradycardia related. Emergent intervention was required in only one patient who developed asystole after cardioversion. Sinus rhythm was restored with chest compressions and the administration of atropine. A temporary pacing catheter was inserted by a cardiologist. A permanent pacemaker placement was inserted 1 day later. The patient made a full recovery and was discharged home without further problems. Another three patients underwent elective pacemaker insertion after DCCV due to nonlife-threatening bradyarrhythmias, including persistent sinus bradycardia and/or Mobitz Type II second degree atrioventricular (AV) block, after the restoration of sinus rhythm. One patient was briefly symptomatic with bradycardia, which resolved after a single dose of 0.2 mg of atropine. No adverse events were reported in patients whose cardioversion attempts failed. There were no deaths or thromboembolic events reported.

Fifty patients had an elective DCCV performed by a cardiologist at our hospital during the same period. The clinical characteristics of this control group are shown in [Table 1] alongside those for the APP group. With the exception of a higher incidence of implanted electronic devices, the control group is statistically similar to the APP group. No significant difference in procedural success rate or incidence of complications was found between the two groups. A notable caveat though is that this comparison is likely to be statistically underpowered.

  Discussion Top

This retrospective study shows that a well-trained APP is capable of performing elective DCCV safely without direct cardiologist supervision. Their procedural success rate of 92% is comparable with the reported success rates of DCCV administered by physicians.[2],[13],[14],[15] The 2006 Guidelines report a range of success rates from 70% to 99% varying with patient characteristics and the waveform used, but also affected by the definition of success used in each study.[2] For example, Niebauer et al. reported “persistent success” rates of 87.1% and 91.9%, respectively, depending on whether the cardioversion was performed with a monophasic or biphasic defibrillator.[13] Their definition of “persistent success” was the maintenance of sinus rhythm when the patient left the procedure room, which is similar to the definition we applied in our cohort. Similarly, Alegret et al. reported a success rate of 87% in a large cohort of 1355 patients.[15] Finally, a study of emergency physicians reported a success rate of 86% in paroxysmal atrial fibrillation, whereas several nurses-led DCCV services in England restored sinus rhythm in 84–92% of the patients.[10],[11],[12],[18]

Concern that DCCV performed by an APP in the presence of an anesthesiologist would compromise patient safety is not supported by our study. The 0.2% complication rate for our APPs falls below the established range from previous publications for DCCV procedures performed by physicians.[1],[2],[3],[4],[5] There were no immediate or delayed events postdischarge in any of our patients.

Transient bradycardia was encountered in some patients and usually resolved spontaneously. Medical therapy is occasionally necessary. Cardiac asystole was extremely rare, and our single occurrence was managed appropriately without further problems. The occurrence of bradycardia after DCCV is not surprising since patients with persistent atrial fibrillation often have concurrent sinus node dysfunction or abnormal AV conduction. Availability of transcutaneous pacing provides an important precaution as a permanent pacemaker can be placed on an elective basis if needed. No immediate or delayed postprocedural thromboembolic event occurred in any of our patients, reflecting the strict adherence to the current anticoagulation guidelines.

There are understandable concerns about the potential legal implications of the practice of cardioversion performed by an APP. In our study, deep sedation and airway management were provided by an anesthesiology team. The designated APPs were well-trained and experienced for their clinical responsibilities. Protocols were in place for adverse event management. An on-call cardiologist was always available for help in challenging cases. In the rare event of an emergency, the hospital rapid action team could be activated immediately. Further patient care remained the responsibility of the delegating physician. Clinical audits for quality assurance were performed regularly.

The delegation of routine elective cardioversions to APPs at our institution, over the past several years, has improved the operational efficiency for the cardiology service. With the recent implementation of the new CMS regulations, no additional cardiologist workforce was added at our hospital. If this model of care is adopted by other institutions, it could also potentially lead to significant cost savings.


This retrospective, observational series is limited by the lack of a sufficiently comparable group of DCCVs performed by our cardiologists. The control group was small and nonrandomized. In spite of this limitation, the elective cardioversions directed by APPs at our institution had an outcome comparable to those reported for cardiologists at other institutions.[1],[2],[3],[4],[5],[13],[14] Further validation requires multicenter randomized trials if necessary.

  Conclusion Top

Under transient deep sedation, administered by the anesthesiology service, elective cardioversion of atrial fibrillation and atrial flutter performed by well-trained APPs, without direct cardiologist supervision, appears to be effective and safe.

Financial support and sponsorship

This study was supported by the Division of Cardiology, Regions Hospital, St. Paul, MN, USA.

Conflicts of interest

Dr. Benditt was supported in part by a philanthropic grant from the Earl E. Bakken family in support of heart-brain research. None of the other authors reported any conflict of interest.

  References Top

Arnold AZ, Mick MJ, Mazurek RP, Loop FD, Trohman RG. Role of prophylactic anticoagulation for direct current cardioversion in patients with atrial fibrillation or atrial flutter. J Am Coll Cardiol 1992;19:851-5.  Back to cited text no. 1
Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. Circulation 2006;114:700-52.  Back to cited text no. 2
Fuster V, Rydén LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. Circulation 2001;104:2118-50.  Back to cited text no. 3
Rabbino MD, Likoff W, Dreifus LS. Complications and limitations of direct-current countershock. JAMA 1964;190:417-20.  Back to cited text no. 4
Killip T. Synchronized DC precordial shock for arrhythmias. Safe new technique to establish normal rhythm may be utilized on an elective or an emergency basis. JAMA 1963;186:1-7.  Back to cited text no. 5
Rodgers GP, Conti JB, Feinstein JA, Griffin BP, Kennett JD, Shah S, et al. ACC 2009 survey results and recommendations: Addressing the cardiology workforce crisis a report of the ACC board of trustees workforce task force. J Am Coll Cardiol 2009;54:1195-208.  Back to cited text no. 6
Centers for Medicare and Medicaid Services (CMS). Clarifications of the Interpretive Guidelines for the Anesthesia Services Condition of Participation and Revised Hospital Anesthesia Interpretive Guidelines-State Operations Manual (SOM) Appendix A, S&C-10-109-Hospital. CMS Publication No. 100-07. Centers for Medicare and Medicaid Services; 2010. www.cms.gov/Regulations-and-Guidance/transmittals/downloads/R59SOMA.pdf. [Last accessed on 2013 May].  Back to cited text no. 7
Limoges-Gonzalez M. Opening doors for nonphysician colonoscopists. Nurse Pract 2012;37:35-40.  Back to cited text no. 8
Pericak A. Increased autonomy for nurse practitioners as a solution to the physician shortage. J N Y State Nurses Assoc 2011;42:4-7.  Back to cited text no. 9
Boodhoo L, Bordoli G, Mitchell AR, Lloyd G, Sulke N, Patel N. The safety and effectiveness of a nurse led cardioversion service under sedation. Heart 2004;90:1443-6.  Back to cited text no. 10
Currie MP, Karwatowski SP, Perera J, Langford EJ. Introduction of nurse led DC cardioversion service in day surgery unit: Prospective audit. BMJ 2004;329:892-4.  Back to cited text no. 11
Shelton RJ, Allinson A, Johnson T, Smales C, Kaye GC. Four years' experience of a nurse-led elective cardioversion service within a district general hospital setting. Europace 2006;8:81-5.  Back to cited text no. 12
Niebauer MJ, Brewer JE, Chung MK, Tchou PJ. Comparison of the rectilinear biphasic waveform with the monophasic damped sine waveform for external cardioversion of atrial fibrillation and flutter. Am J Cardiol 2004;93:1495-9.  Back to cited text no. 13
Van Gelder IC, Crijns HJ, Van Gilst WH, Verwer R, Lie KI. Prediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current electrical cardioversion of chronic atrial fibrillation and flutter. Am J Cardiol 1991;68:41-6.  Back to cited text no. 14
Alegret JM, Viñolas X, Sagristá J, Hernandez-Madrid A, Pérez L, Sabaté X, et al. Predictors of success and effect of biphasic energy on electrical cardioversion in patients with persistent atrial fibrillation. Europace 2007;9:942-6.  Back to cited text no. 15
Yurchak PM, Williams SV, Achord JL, Klocke FJ, Reynolds WA, Akhtar M, et al. ACP/ACC/AHA task force statement: Clinical competence in elective direct current (DC) cardioversion. J Am Coll Cardiol 1993;22:336-9.  Back to cited text no. 16
Oral H, Souza JJ, Michaud GF, Knight BP, Goyal R, Strickberger SA, et al. Facilitating transthoracic cardioversion of atrial fibrillation with ibutilide pretreatment. N Engl J Med 1999;340:1849-54.  Back to cited text no. 17
Burton JH, Vinson DR, Drummond K, Strout TD, Thode HC, McInturff JJ. Electrical cardioversion of emergency department patients with atrial fibrillation. Ann Emerg Med 2004;44:20-30.  Back to cited text no. 18


  [Table 1], [Table 2]

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