A comparison of early versus delayed elective electrical cardioversion for recurrent episodes of persistent atrial fibrillation: A multi-center study

Background: Due to barriers to accessing timely elective electrical cardioversion (CV) for persistent AF (PeAF), we adopted a policy of instructing patients to present directly to the Emergency Department (ED) for CV. Objective: We compare a strategy of Emergency CV (ED-CV) versus Elective CV (EL-CV) for treatment of symptomatic PeAF. Methods: Between 2014 and 7, we evaluated 150 patients undergoing CV for PeAF. ED-CV patients were provided an AF action plan for recurrent symptoms and advised to present to ED within 36 h. EL-CV patients followed standard care, including cardiologist referral and placement on an elective hospital waiting list. Follow-up was 12 months. Results: We included 75 consecutive ED-CV patients and 75 consecutive EL-CV patients. ED-CV patients had a significantly shorter median AF duration prior to CV (1 day vs 3 months; p < 0.01) and less overall AF-related symptoms at 12 months (modified EHRA symptom score ≥ 2a in 44% vs 72%; p = 0.005). Time to next AF recurrence was longer in the ED-CV group (295 ± 15 vs 245 ± 15 days; logrank p = 0.001), as was time to AF ablation referral (314 ± 13 vs 276 ± 15 days; logrank p = 0.01). Baseline LA area was similar (ED-CV 27 ± 4 cm ² vs EL-CV 28 ± 11 cm ² ; p = 0.67), however EL-CV had larger atria at follow-up (31 ± 8 vs 26 ± 6 cm ² ; p = 0.01). There were no complications in either group. Conclusion: ED-CV is an acceptable strategy for symptomatic PeAF. In addition to reduced time spent in AF and improved symptom scores, this strategy may also slow progression of atrial substrate & delay onset of next AF episode.