Objective To compare the efficacy and safety of cryoballoon ablation versus electrical cardioversion in patients with first-episode, untreated persistent atrial fibrillation. Methods Patients with first-episode persistent atrial fibrillation who received cryoballoon ablation or electrical cardioversion in our hospital were enrolled. Propensity score matching was applied to balance baseline characteristics, and a total of 70 patients with atrial fibrillation duration <1 year were finally included, with 35 in the cryoballoon group and 35 in the cardioversion group. The primary efficacy endpoint was the freedom from atrial fibrillation recurrence at 1 year post-procedure, and the safety endpoint was the incidence of major complications. Results The 1-year freedom from recurrence rate was significantly higher in the cryoballoon group than in the cardioversion group (76.6% vs. 45.0%, P<0.05). No significant difference was observed between the 2 groups in the incidence of severe complications such as stroke or cardiac tamponade. Left atrial diameter was identified as an independent risk factor for recurrence after cryoballoon ablation (hazard ratio=1.319, P=0.046), whereas atrial fibrillation duration was an independent risk factor for recurrence after cardioversion (hazard ratio=1.131, P=0.037).Conclusions For patients with first-episode persistent atrial fibrillation, cryoballoon ablation is superior to electrical cardioversion in maintaining sinus rhythm, with a favorable safety profile. Left atrial diameter and atrial fibrillation duration are important predictors of recurrence after each treatment modality, which may help guide individualized clinical decision-making.