REVERSE-AF Score: development of a clinical tool to predict atrial fibrillation recurrence after electrical cardioversion

Background Electrical cardioversion (ECV) restores sinus rhythm in atrial fibrillation (AF), yet recurrence within 12 months remains frequent. Metabolic, respiratory and structural atrial factors, along with age and arrhythmia duration, may critically influence long-term rhythm maintenance. Objectives To characterize a real-world ECV cohort, identify predictors of AF recurrence, and develop a pragmatic clinical score to stratify recurrence risk. Methods This retrospective study included 787 patients undergoing electrical cardioversion between January 2018 and June 2025 at a single hospital center (ambulatory and emergency settings). Clinical and echocardiographic data were collected. The primary endpoint was AF recurrence at 12 months. Independent predictors were identified using multivariable logistic regression, and a simplified clinical risk score was derived from clinically relevant variables. Model discrimination, calibration, and optimal threshold were assessed using ROC curve analysis, Youden’s index, and the Hosmer–Lemeshow test, with internal validation performed through resampling techniques. Time to AF recurrence according to score categories was analyzed using Kaplan–Meier methods. Results Mean age was 66.3 ± 10.4 years; 63% were male and 72% had persistent AF (median duration 8 months). Obesity (BMI ≥30 kg/m²) was present in 43%, Obstructive sleep apnea in 32%, and mean Left Atrial Volume Index (LAVI) was 43 ± 12 mL/m². Acute ECV success was 89%, with 12-month recurrence of 54.6%. Independent predictors of recurrence included: Obesity (OR 1.84; p=0.006), Obstructive sleep apnea (OR 1.91; p=0.017), LAVI > 48 mL/m² (OR 1.63; p=0.041). Age ≥70 years and AF duration >12 months were both statistically significant in univariate analysis. Due to strong physiological plausibility, they were retained and incorporated into the scoring model. The REVERSE-AF score (0–7 points) was derived: Obesity (2 points), Obstructive sleep apnea (2 points), LAVI > 48 mL/m² (1 point), age ≥ 70 years (1 point), and AF duration >12 months (1 point). ROC analysis demonstrated moderate discrimination and acceptable calibration, with an AUC consistent with clinically useful prediction (AUC 0.71; 95% CI 0.67–0.75). The optimal Youden-derived threshold was ≥3 points, yielding a sensitivity of 78% and a specificity of 55%. Patients with scores ≥4 demonstrated recurrence probabilities exceeding 70%, whereas those scoring ≥6 points approached recurrence rates above 90%. Conclusions Obesity, Obstructive sleep apnea and left atrial enlargement are the strongest independent predictors of AF recurrence after ECV. The REVERSE-AF score provides a simple, intuitive tool for risk stratification, identifying patients with moderate risk at ≥ 3 points and those with high likelihood of recurrence at ≥ 4 points. This score may support clinical decision-making. Prospective validation is warranted.