BackgroundParoxysmal atrial fibrillation (pAF) may progress through cardiac remodeling to persistent atrial fibrillation (psAF). However, some may present in psAF without a preceding history of pAF. A preceding history of pAF may affect recurrence following direct current cardioversion (DCCV). ObjectiveTo determine if a preceding history of pAF is associated with a difference in recurrence rates after DCCV compared to patients without a preceding history of pAF. MethodsA prospective procedural database at a Veterans Affairs center identified 565 patients who underwent their first DCCV for psAF. Initial rhythm history was separated by prior pAF and those with none were considered primary psAF. ECG follow-up was standardized at 1- and 3- months post cardioversion. ResultsPatients who underwent their first DCCV for psAF were more likely to have presented with primary psAF (81.6%). Those with pAF had a similar left atrial size, but were more likely to have chronic kidney disease, sleep apnea, previous stroke, and utilizing antiarrhythmic drugs at the time of cardioversion. Patients with pAF had earlier recurrence and shorter median AF survival time, 1.6 months compared to 5 months (Kaplan-Meier plot p=0.0101). This difference persisted when controlling for AAD use. Recurrence type was mostly persistent AF, similar in both groups. ConclusionPatients with primary psAF may have a more sustained response to DCCV when compared to those with a preceding history of pAF. Thus, those patients with pAF may benefit from a more aggressive, early rhythm control strategy due to higher likelihood of recurrence with DCCV.