title: Lack of prevention of heart failure by serial electrical cardioversion in patients with persistent atrial fibrillation.
abstract: OBJECTIVE
  To investigate the occurrence of heart failure complications, and to identify variables that predict heart failure in patients with (recurrent) persistent atrial fibrillation, treated aggressively with serial electrical cardioversion and antiarrhythmic drugs to maintain sinus rhythm.
  
  
  METHODS
  Non-randomised controlled trial; cohort; case series; mean (SD) follow up duration 3.4 (1.6) years.
  
  
  METHODS
  Tertiary care centre.
  
  
  METHODS
  Consecutive sampling of 342 patients with persistent atrial fibrillation (defined as > 24 hours duration) considered eligible for electrical cardioversion.
  
  
  METHODS
  Serial electrical cardioversions and serial antiarrhythmic drug treatment, after identification and treatment of underlying cardiovascular disease.
  
  
  METHODS
  heart failure complications: development or progression 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 were related to the presence of coronary artery disease (p < 0.001, risk ratio 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 (New 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 patients with lone atrial fibrillation.
  
  
  CONCLUSIONS
  Aggressive serial electrical cardioversion does not prevent heart failure complications in patients with persistent atrial fibrillation. These 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 fibrillation in relation to heart failure.
authors.affiliation: Department of Cardiology, Thoraxcenter, University Hospital Groningen, 9700 RB Groningen, Netherlands.
authors.forename: A E
authors.initials: AE
authors.lastname: Tuinenburg
authors.forename: I C
authors.initials: IC
authors.lastname: Van Gelder
authors.forename: M P
authors.initials: MP
authors.lastname: Van Den Berg
authors.forename: J
authors.initials: J
authors.lastname: Brügemann
authors.forename: P J
authors.initials: PJ
authors.lastname: De Kam
authors.forename: H J
authors.initials: HJ
authors.lastname: Crijns
mesh_terms: D000368:Aged; D000638:Amiodarone / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications* / Q000401:mortality / Q000628:therapy*; D004554:Electric Countershock; D005260:Female; D005424:Flecainide / Q000627:therapeutic use; D005500:Follow-Up Studies; D006333:Heart Failure / Q000209:etiology* / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012306:Risk; D013015:Sotalol / Q000627:therapeutic use; D017211:Treatment Failure; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants; D014859:Warfarin; D013015:Sotalol; D005424:Flecainide; D000638:Amiodarone