Predictors of electrical vs pharmacologic cardioversion in critically ill patients with atrial fibrillation

Atrial fibrillation (AF) is common in critically ill patients and may worsen hemodynamic instability. Cardioversion is often required for rhythm control. Factors influencing the choice between electrical and pharmacologic cardioversion remain unclear. This study evaluated whether clinical variables, including age, acute coronary syndrome, acute respiratory failure, chronic heart failure, and hypertension, are associated with cardioversion strategy. A retrospective observational study was conducted using the Atrial Fibrillation in Critically Ill dataset. Critically ill adult patients with preexisting AF admitted to the ICU were included. The primary outcome was cardioversion strategy (electrical versus pharmacologic) during hospitalization. Predictor variables included age, ACS, ARF, CHF, and HTN. Multivariable logistic regression analysis was performed using Stata (BE 19) to estimate adjusted odds ratios with 95% confidence intervals. Among 1,705 critically ill patients with AF, 179 (10.5%) underwent electrical cardioversion and 290 (17.0%) received pharmacologic cardioversion. ARF was present in 397 patients (23.3%), ACS in 212 patients (12.4%), CHF in 693 patients (40.6%), and HTN in 838 patients (49.1%). Hypertension was associated with increased electrical cardioversion, possibly representing a more stable patient subset. Overall, these findings support a context-driven approach to cardioversion in critically ill patients, prioritizing physiologic stability and reversibility of illness.