A comparison of early versus delayed elective electrical cardioversion for recurrent episodes of persistent atrial fibrillation

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As an emerging epidemic of cardiovascular disease, increasing numbers of patients are utilizing electrical cardioversion (CV) for treatment of symptomatic persistent atrial fibrillation (PeAF). The timing of CV following AF recurrence is dictated by a combination of factors, including patient symptoms, physician preference and resource availability. In addition to adverse effects on quality of life from prolonged AF duration, progressive adverse electrical and structural changes occur in the atria at different time points following arrhythmia onset . The clinical implications of delayed CV for intermittent PeAF are not well categorized, although some studies suggest these patients are at higher risk of AF recurrence . Due to barriers to accessing early elective cardioversion, including time taken to see a family physician, obtain specialist referral and wait for a scheduled CV, we adopted a policy of instructing patients to present directly to the Emergency department for early cardioversion. We sought to retrospectively compare a strategy of early ‘Emergency’ CV versus delayed ‘Elective’ CV for treatment of intermittent PeAF. We hypothesized that benefits of early CV may extend beyond symptoms, including prevention of adverse remodelling, reduction in recurrence risk and potentially lower utilization of AF ablation. In this observational retrospective cohort study, we plan to evaluate 150 patients presenting with symptomatic PeAF presenting to two centers in metropolitan Melbourne between 2/2014 – 7/2017. All included patients have a history of persistent AF, as defined by a previous or current episode of AF lasting longer than 7 days. We seek to compare two patient groups – those treated with Emergency vs Elective cardioversion strategies and included 75 consecutive patients from each group. Follow-up is over 12 months. Follow up for 12 months following cardioversion includes 12-lead ECG at onset of symptoms and during outpatient review at 3 months post discharge and 6 – 12 monthly thereafter. Referral for AF ablation is routinely initiated for symptomatic AF despite 1 – 2 antiarrhythmic agents. The primary endpoint is time to persistent AF recurrence. Secondary endpoints include AF duration prior to CV, changes in left atrial (LA) size on echocardiography from baseline to follow-up, modified European Heart Rhythm Association (EHRA) score at 12 months and time to referral for AF ablation. Medical records, including specialist and family physician visits, emergency and inpatient discharge summaries and echocardiographic data will be reviewed for recurrences, subsequent referrals for AF ablation and other endpoints.

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