Lack of prevention of heart failure by serial electrical cardioversion in patients with persistent atrial fibrillation

Objective-To investigate the occurrence of heart failure complications, and to identify variables that predict heart failure in patients with (recurre nt) persistent atrial fibrillation, treated aggressively with serial electr ical cardioversion and antiarrhythmic drugs to maintain sinus rhythm. Design-Non-randomised controlled trial; cohort; case series; mean (SD) foll ow up duration 3.4 (1.6) years. Setting-Tertiary care centre. Subjects-Consecutive sampling of 342 patients with persistent atrial fibril lation (defined as > 24 hours duration) considered eligible for electrical cardioversion. Interventions-Serial electrical cardioversions and serial antiarrhythmic dr ug treatment, after identification and treatment of underlying cardiovascul ar disease. Main outcome measures-heart failure complications: development or progressi on of heart failure requiring the institution or addition of drug treatment , hospital admission, or death from heart failure. Results-Development or progression of heart failure occurred in 38 patients (11%), and 22 patients (6%) died from heart failure. These complications w ere related to the presence of coronary artery disease (p < 0.001, risk rat io 3.2, 95% confidence interval (CI) 1.6 to 6.5), rheumatic heart disease ( p < 0.001, risk ratio 5.0, 95% CI 2.4 to 10.2), cardiomyopathy (p < 0.001, risk ratio 5.0, 95% CI 2.0 to 12.4), atrial fibrillation for < 3 months (p = 0.04, risk ratio 2.0, 95% CI 1.0 to 3.7), and poor exercise tolerance (Ne w York Heart Association class III at inclusion, p < 0.001, risk ratio 3.5, 95% CI 1.9 to 6.7). No heart failure complications were observed in patien ts with (one atrial fibrillation. Conclusions-Aggressive serial electrical cardioversion does not prevent hea rt failure complications in patients with persistent atrial fibrillation. T hese complications are predominantly observed in patients with more severe underlying cardiovascular disease, Randomised comparison with rate control treatment is needed to define the optimal treatment for persistent atrial f ibrillation in relation to heart failure.