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October 21, 2025 Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 S570

Wigginton et al Advanced Life Support: 2025 AHA Guidelines for CPR and ECC

cardioversion success for atrial flutter between these waveforms at the same energy settings, ranging from 50% to 75% at 50 J, improving to 85% to 90% at 100 J, and approaching 100% at 200 J.23,28,36–38 Using a higher (200 J) initial energy setting for flutter cardioversion also affords shorter procedural times without causing cardiac injury or compromising safety,23,26,36–38 accompanied by a lower risk of provoking AF or undertreating AF if mistaken as flutter.27,36 The likelihood of greater efficacy, efficiency, and simplicity, without safety concerns, supports a starting energy of 200 J for flutter cardioversion using any currently US-marketed biphasic defibrillator; incremented in the event of shock failure, depending on the defibrillator’s features.23,28,36,37

6 Shock-refractory AF, defined as AF that

remains incessant after maximum-energy shocks, is relatively uncommon with biphasic shock waveforms and distinguished from recurrent AF, which returns after an initially successful shock. As in many situations, shock success can be optimized by minimizing transthoracic impedance3 by improving pad-skin contact and applying pad pressure; relocating pads to redirect the shock vector; or adding antiarrhythmic drugs to alter the defibrillation threshold.2,5,6,39,40 Another possibility is the use of double synchronized cardioversion.41 Data on this approach are limited, including procedural uncertainties described above (item 4). Observational studies found doublesynchronized cardioversion to be successful in 75% to 100% of patients who had previously failed standard cardioversion.41–43 Alternatively, a large prospective observational study evaluated a systematic approach to shockrefractory AF. It found applied pad pressure improved synchronized cardioversion success from 87% to 93% and with pad repositioning to 96%, after which the added increment from double-synchronized cardioversion only modestly improved to 98%.2

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