Peak atrial longitudinal strain in predicting recurrence of atrial fibrillation after cardioversion

Background Elective cardioversion of patients with atrial fibrillation (AF) is widely used to achieve a normal sinus rhythm, however the rates of rhythm maintenance in the long term remain sub-optimal. Structural atrial remodelling, including fibrosis and reduced compliance, play a key role in the persistence of AF. Peak atrial longitudinal strain (PALS) is an echocardiographic measurement of the stiffness and quantity of fibrosis in the atria, and has been associated with increased symptomatic burden and recurrence of AF, however there is currently little research on the use of this value in clinical decision making. Purpose To investigate if pre-cardioversion PALS measurements can be used to predict early recurrence of AF following cardioversion. Methods Through a real-life retrospective study, 137 patients, who were electively cardioverted in 2025 and subsequently followed up in an outpatient clinic within 2 months, were evaluated for their long-term rhythm status with an electrocardiogram or holter exam. Patients were excluded if they did not have adequate pre-cardioversion cardiac ultrasound imaging, were in sinus rhythm during the echo or were taking antiarrhythmics such as amiodarone or flecainide. Atrial speckle-tracking analysis was performed on the most recent echocardiographic exam prior to cardioversion to calculate PALS, via the use of automated tools available in echoPACS. Results In total, 55 patients were included in the study, with 25 (45.5%) patients maintaining a sinus rhythm and 30 (54.5%) converting back to AF. The average PALS value in patients with recurrence was 9 and in patients that maintained their sinus rhythm, the average was 13. Logistic regression modelling calculated a chi-squared of 6.73 (p=<0.05), indicating a statistically significant prediction as compared to the null model. The odds-ratio of PALS to successfully maintaining sinus rhythm was 1.14 (p=<0.05) with a 95% confidence interval of 1.02 - 1.27, implying that with every increase in PALS by a unit of 1, there is a statistically significant increased rate of maintaining sinus rhythm by 14%. Conclusion Pre-cardioversion PALS strongly is associated with increased rates of early AF recurrence following cardioversion. Its use in the clinical setting can be used to improve patient selection and individualised rhythm control strategies, thereby avoiding unnecessary cardioversions for patients and freeing up resources.