Hemodynamic and Metabolic Predictors of Unsuccessful Electrical Cardioversion or Early Atrial Fibrillation Recurrence After Electrical Cardioversion

Background: Rhythm control remains a cornerstone in the management of atrial fibrillation (AF). Although electrical cardioversion (ECV) effectively restores sinus rhythm (SR), its short-term durability is limited. Aims: This study aimed to evaluate the short-term rhythm outcomes after ECV and to identify predictors of failure to achieve or maintain SR within 30 days after ECV, with particular emphasis on the hemodynamic profile of patients with persistent AF. Methods: Ninety-four consecutive patients with persistent AF undergoing elective ECV were prospectively enrolled. Cardiac rhythm was assessed immediately after ECV, at ~24 h, and ~30 days. Laboratory testing, echocardiography, and impedance cardiography (ICG) were performed before ECV. Logistic regression analysis was used to identify predictors of failure to achieve or maintain SR within 30 days after ECV. Results: ECV was initially successful in 80 patients (85.1%), with SR maintained in 76 (80.8%) at 24 h. At 30 days, SR persisted in 49 patients (52.1%), while 43 patients (45.7%) failed to achieve or maintain SR, including 14 patients in whom ECV was unsuccessful and 29 patients who experienced AF recurrence after initially successful ECV; two patients were lost to follow-up. In multivariable analysis, T2DM was independently associated with higher odds of failure to achieve or maintain SR within 30 days after ECV (OR 3.26; 95% CI 1.183–8.978; p = 0.022). Higher TFC values were also independently associated with increased odds of this outcome (OR 1.15; 95% CI 1.017–1.291; p = 0.025). In contrast, the presence of hypertension was associated with lower odds of this outcome (OR 0.30; 95% CI 0.094–0.947; p = 0.040). Among hemodynamic parameters, only TFC was independently associated with the outcome, whereas echocardiographic parameters did not differ between groups. Conclusions: Even in a relatively low-risk population without advanced comorbidity burden, failure to achieve or maintain SR after ECV remains frequent. T2DM and elevated TFC were independently associated with failure to achieve or maintain SR, while hypertension was associated with a lower risk. These findings suggest that metabolic and hemodynamic abnormalities may provide prognostic information beyond that captured by conventional echocardiography.