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Introduction: Atrial fibrillation (AF) increases the risk for stroke, dementia, and impaired health-related quality of life (HRQL). Elective direct current cardioversion (ECV) is often used to restore sinus rhythm but is associated with thromboembolism. While larger strokes usually produce symptoms, subclinical ones may go unrecognized and may cause cognitive and functional decline over time. In the current study, we sought to evaluate the effects of ECV on silent brain infarctions and HRQL in patients with AF. Methods: Patients with AF (n = 46) underwent brain magnetic resonance imaging (MRI) and HRQL assessment using the EuroQL-5D5L questionnaire before and after ECV. Implantable loop recorders (ILRs) were used to observe the rate of early AF recurrences within the first 30 days. All patients were treated with anticoagulants according to guidelines. The primary endpoint was silent brain infarction assessed by brain MRI within the first 2 weeks after ECV. Secondary endpoints were the change in HRQL and its association with AF recurrence at follow-up and by ILR recordings. Results: New silent brain infarction after ECV was detected in 1 patient. At follow-up visit after 19.1 days AF recurrence was detected by 12-lead ECG in 13 patients (28.3%), whereas 27 patients (58.7%) had AF recurrence recorded by ILR within the first 30 days after ECV. European Heart Rhythm Association (EHRA) symptom score and the EuroQL-5d5L score were improved after ECV. Conclusion: Silent brain infarctions may occur after ECV despite anticoagulation treatment. Early AF recurrence is frequent. ECV positively affects HRQL mainly in those patients with sustained sinus rhythm at follow-up. Plain Language Summary: Electric shock treatment is safe and well tolerated in the most common form of heart arrhythmia. The most common form of heart arrhythmia in humans is called AF. This affects up to 1/3 of the general population in their lifetime. Many people with this condition develop symptoms such as breathlessness and chest pain. Even worse, this arrhythmia increases the risk of developing stroke dramatically. Common treatments include medicines that prevents the blood from clotting and thereby forming strokes and small, timed electric impulses to restore a regular rhythm. However, the transition from arrhythmia to a regular heart rhythm increases the risk for stroke as well, albeit only for a short time. Moreover, not all small strokes are necessarily immediately symptomatic. In this work, researchers used advanced imaging diagnostic to find out how often this may happen. They found out, that most people really felt better, though 1/3 of the patients may develop a relapse of their arrhythmia. Small strokes after the procedure were not a regular finding. However they may still develop, as seen in one patient in this study despite appropriate medicine to prevent blood clots. [ABSTRACT FROM AUTHOR]