Electrocardiographic Predictors of Early Recurrence of Atrial Fibrillation After Electrical Cardioversion

BACKGROUND: Although electrical cardioversion (ECV) effectively restores sinus rhythm in patients with persistent atrial fibrillation (AF), early recurrence after successful ECV remains common in clinical practice. We investigated whether simple 12-lead electrocardiographic markers and a composite ECG score could predict early AF recurrence. METHODS: We retrospectively analyzed 195 patients with persistent AF who underwent successful ECV. Electrocardiograms recorded immediately after ECV were evaluated for notched P-wave, fragmented QRS (fQRS), and early repolarization pattern (ERP). The ECG composite score was defined as the sum of these markers (0-3). Early AF recurrence was defined as electrocardiographically documented recurrence within 10 days after ECV. Multivariable logistic regression analysis was performed. RESULTS: Early AF recurrence occurred in 100 patients (51.3%). AF duration was longer in patients with recurrence (12 [3-57] vs. 5 [2-15] months, p < 0.001). Notched P-wave (76.0% vs. 24.2%, p < 0.001), fQRS (74.0% vs. 57.9%, p = 0.017), and ERP (41.0% vs. 24.2%, p = 0.015) were more frequent in patients with recurrence. In multivariable analysis, notched P-wave (OR 11.80), fQRS (OR 2.34), and ERP (OR 3.54) independently predicted recurrence (all p < 0.05). The ECG composite score was also independently associated with recurrence (OR 4.91 per 1-point increase, p < 0.001), with a stepwise increase in recurrence across score categories. CONCLUSIONS: Simple 12-lead ECG markers and a composite ECG score may help predict early AF recurrence and guide rhythm-control strategies after ECV in patients with persistent AF.