Background: The best strategy to assess the association between symptoms and rhythm status (symptom-rhythm correlation) in patients with atrial fibrillation (AF) remains unclear. We aimed to determine the clinical utility of rhythm control by electrical cardioversion (ECV) to assess symptom-rhythm correlation in patients with persistent AF.

Methods: We used ECV to examine symptom-rhythm correlation in 81 persistent AF patients. According to current clinical practice, the presence of self-reported symptoms before ECV and at the first outpatient clinic follow-up visit (within 1-month) was assessed to determine the prevalence of a symptom-rhythm correlation (defined as self-reported symptoms present during AF and absent in sinus rhythm or absent in AF and yet relief during sinus rhythm). In addition, we evaluated symptom patterns around ECV.

Results: Only in 18 patients (22%), a symptom-rhythm correlation could be documented. Twenty-eight patients (35%) did not show any symptom-rhythm correlation and 35 patients (43%) had an unevaluable symptomrhythm correlation as these patients were in symptomatic AF both at baseline and at the first outpatient AF clinic follow-up visit. Importantly, self-reported symptom patterns around ECV were intra-individually variable in 10 patients (12%) without symptom-rhythm correlation (of which 9 patients (11%) had AF recurrence) and in 2 patients (2%) with an unevaluable symptom-rhythm correlation.

Conclusions: In patients with persistent AF, symptom assessment around rhythm control by ECV, once before ECV and once within 1-month follow-up, rarely identifies a symptom-rhythm correlation and often suggests changes in symptom pattern. Better strategies are needed to assess symptom-rhythm correlation in patients with persistent AF.