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BACKGROUND: Direct current cardioversion (DCCV) is commonly performed for atrial fibrillation and flutter (AF/AFL). However, temporal trends and contemporary practices surrounding DCCV are poorly characterized.OBJECTIVE: To analyze a large multi-institutional experience of DCCV over two decades, quantifying trends, outcomes, and management strategies.METHODS: For case-level analyses, we identified all DCCVs for AF/AFL between 2000-2024 and assessed annual volumes and patient status at the time of DCCV (i.e., outpatient, inpatient, or emergency/observation). For patient-level analyses, we focused on individuals who underwent their first (index) DCCV between 2000-2022. We evaluated baseline characteristics and outcomes following index DCCV, including AF/AFL recurrence, stroke, heart failure (HF), HF hospitalization, and catheter ablation.RESULTS: We identified 44,043 DCCVs with annual cases increasing substantially from 857 in 2000 to 3,999 in 2024. Most DCCVs were performed with outpatient status (n=21,966, 49.9%), followed by inpatient (n=17,833, 40.5%). Among 19,848 patients (age 66.9±12.9 years, 31.5% female) who underwent index DCCV between 2000-2022, the cumulative risk of AF/AFL recurrence was 50.5% (95% confidence interval [CI]: 49.8-51.2) at 1 year and 75.4% (74.7-76.2) at 5 years. The 5-year cumulative risk was 15.8% (15.2-16.4) for incident stroke, 28.1% (27.2-29.1) for incident HF, and 24.9% (24.2-25.6) for HF hospitalization. Catheter ablation within two years after index DCCV increased substantially over time.CONCLUSIONS: DCCV case volume has increased markedly, and subsequent catheter ablation is increasingly common. Findings highlight a growing preference for rhythm control and emphasize the importance of scaling access to DCCV.