Clinical implications of failed electrical cardioversion in long-standing persistent atrial fibrillation

Ku et al. recently reported clinical predictors of failed electrical cardioversion (ECV) in patients with persistent or long-standing persistent atrial fibrillation. While the multicentre cohort and comprehensive echocardiographic assessment provide valuable data, several methodological and interpretative issues merit further discussion. These include the retrospective design and potential residual confounding, heterogeneity in ECV protocols across centres, reliance on intermittent rhythm monitoring for outcome assessment, and limited integration of contemporary atrial cardiomyopathy concepts into risk stratification. Moreover, the clinical implications of preferring rate control in high-risk subgroups require cautious interpretation in light of modern rhythm-control evidence. Addressing these aspects may enhance the translational impact of the findings and refine patient selection for rhythm-control strategies.