Direct current cardioversion (DCCV) as a treatment for persistent atrial fibrillation (AF) was first introduced in the 1960s.1 It has become a standard medical procedure performed in almost all hospitals with an acute medical unit in the UK. Much has changed in the management of AF in recent years and with the explosion of interest in AF ablation and the introduction of the NICE guidelines on AF management last year (http://guidance.nice.org.uk/CG36 (accessed 16 April 2008)) now is an appropriate time to ask if we are using the technique to best effect.

Several series following the results from unselected patients undergoing DCCV for AF have shown that sinus rhythm (SR) is achieved at the time of the procedure in about 85% of patients, but that at the end of 1 year, only 30–40% of these will still be in SR, the remainder having reverted to AF; yet, in those patients where SR has been achieved and maintained, a significant improvement in left ventricular performance, exercise capacity and heart failure symptoms can be expected.2 The disappointingly high rate of reversion to AF after DCCV has led to the use of antiarrhythmic drugs to try to increase the number of patients remaining in SR. In some trials these have been started following the cardioversion, but more usually patients were preloaded before DCCV and the drug then continued for a period after the procedure. The most notable example of this approach was probably the SAFE-T trial, which showed freedom from AF recurrence with amiodarone for a mean of 487 days compared with 74 days with sotalol and 6 days with placebo, according to intention-to-treat analysis.3 These observations informed the advice shown on page 11 of the NICE …