Atrial fibrillation signal organization predicts sinus rhythm maintenance in patients undergoing cardioversion of atrial fibrillation

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Electrical remodelling is believed to influence the outcome following cardioversion of patients with persistent atrial fibrillation (AF). However, the results in clinical studies are conflicting. We assessed the hypothesis that non-invasively obtained atrial fibrillatory organization can be used as a predictor of sinus rhythm (SR) maintenance.

Methods and results

Fifty-four patients (37 men, age 67±11) with persistent AF (median duration 3 months, 1 day to 18 months), without anti-arrhythmic drug treatment, referred for cardioversion were studied. Assessment of the atrial harmonic decay was made by time–frequency analysis of the ECG. At 1-month follow-up, 30 patients had relapsed into AF. The mean harmonic decay at inclusion of those relapsing into AF was 1.5±0.3 compared with 1.1±0.3 among those maintaining SR (P=0.0004). Using a cut-off value of harmonic decay ≤1.5 to determine suitability for cardioversion would have resulted in a clinically useful discriminator (sensitivity=92%, specificity=47%, PPV=59%, and NPV=88%).


This study shows that patients relapsing rapidly to AF have a higher harmonic decay than those maintaining SR. The degree of AF signal organization (harmonic decay) was a superior discriminator to other patient parameters. Further studies are needed to confirm these results and to determine the electrophysiological correlate of harmonic decay.

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