title: Is there an association between external cardioversions and long-term mortality and morbidity? Insights from the Atrial Fibrillation Follow-up Investigation of Rhythm Management study.
abstract: BACKGROUND
  Cardiac electric therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardioverter-defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regard to cardiovascular mortality and morbidity.
  
  
  RESULTS
  We analyzed the data of the 4060 patients from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality, and hospitalizations after ECVe were studied. Over an average follow-up of 3.5 years, 660 (16.3%) patients died, 331 (8.2%) from cardiovascular causes. A total of 207 (5.1%) and 1697 (41.8%) patients had low ejection fraction and nonparoxysmal atrial fibrillation, respectively; 2460 patients received no ECVe, whereas 1600 experienced ≥ 1 ECVe. Death occurred in 412 (16.7%), 196 (16.5%), 39 (13.5%), and 13 (10.4%) of patients with 0, 1, 2, and ≥ 3 ECVe, respectively. There was no significant association between ECVe and mortality within any of the 4 subgroups defined by ejection fraction and atrial fibrillation type, although myocardial infarction, coronary artery bypass graft, and digoxin were significantly associated with death (estimated hazard ratios, 1.65, 1.59, and 1.62, respectively; P < 0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% versus 5.8%; estimated odds ratio, 1.39; P < 0.0001).
  
  
  CONCLUSIONS
  In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, myocardial infarction, and coronary artery bypass graft were significantly associated with mortality.
authors.affiliation: University of Kentucky, Lexington, KY, USA. samy-claude.elayi@uky.edu
authors.forename: Claude S
authors.initials: CS
authors.lastname: Elayi
authors.forename: Matthew G
authors.initials: MG
authors.lastname: Whitbeck
authors.forename: Richard
authors.initials: R
authors.lastname: Charnigo
authors.forename: Jignesh
authors.initials: J
authors.lastname: Shah
authors.forename: Tracy E
authors.initials: TE
authors.lastname: Macaulay
authors.forename: Gustavo
authors.initials: G
authors.lastname: Morales
authors.forename: John C
authors.initials: JC
authors.lastname: Gurley
authors.forename: Bahram
authors.initials: B
authors.lastname: Kakavand
authors.forename: Sergio
authors.initials: S
authors.lastname: Thal
authors.forename: Chi Keong
authors.initials: CK
authors.lastname: Ching
authors.forename: Yaariv
authors.initials: Y
authors.lastname: Khaykin
authors.forename: Atul
authors.initials: A
authors.lastname: Verma
authors.forename: Conor
authors.initials: C
authors.lastname: Barrett
authors.forename: Rong
authors.initials: R
authors.lastname: Bai
authors.forename: Luigi
authors.initials: L
authors.lastname: Di Biase
authors.forename: Abhijit
authors.initials: A
authors.lastname: Patwardhan
authors.forename: David J
authors.initials: DJ
authors.lastname: Moliterno
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000401:mortality* / Q000628:therapy*; D001026:Coronary Artery Bypass / Q000401:mortality; D017147:Defibrillators, Implantable; D004077:Digoxin / Q000627:therapeutic use; D004554:Electric Countershock; D005500:Follow-Up Studies; D006760:Hospitalization; D006801:Humans; D009203:Myocardial Infarction / Q000401:mortality; D015996:Survival Rate
chemical_list: D000889:Anti-Arrhythmia Agents; D004077:Digoxin