Risk factors of failed electrical cardioversion in patients with persistent or long-standing persistent atrial fibrillation

Background/aims Identifying clinical risk factors of failed electrical cardioversion (ECV) for persistent or long-standing persistent atrial fibrillation (AF) can guide selection of rhythm control.Methods A total of 1058 patients who underwent ECV for persistent or long-standing persistent AF at multiple centres were retrospectively reviewed. Patients were divided into three groups: group 1 maintained sinus rhythm (SR) for >1 year, group 2 maintained SR ≤1 year after ECV, and group 3 had failed ECV. SR maintenance was assessed via regular electrocardiography follow-ups or Holter.Results Group 1, 2 and 3 comprised 315 (30%), 654 (62%), and 89 (8%) patients, respectively. The mean patient age was 61 ± 10 years, with males accounting for 78% (824). Group 3 showed longer AF duration, female dominance, high proportion of patients with history of coronary artery disease (CAD) and heart failure (HF), and increased left atrium (LA) diameter, LA volume index (LAVI), cardiac size, and cardiothoracic ratio. Univariate analysis revealed that AF duration (≥50 months), female sex, history of CAD and HF, increased LA diameter (≥ 45 mm) and LAVI (≥ 45 mL/m2), and no antiarrhythmics were risk factors of failed ECV for persistent or long-standing persistent AF. Among them, AF duration (≥50 months), history of HF, and increased LAVI showed clinical significance in the multivariate analysis.Conclusions Longer AF duration, history of HF, and increased LAVI were strongly associated with failed ECV in patients with persistent or long-standing persistent AF.