Recommendations for Prevention of Thromboembolism in the Setting of Cardioversion

Referenced studies that support the recommendations are summarized in the Online Data Supplement.

COR	LOE	Recommendations
1	B-R	1. In patients with AF duration of ≥48 hours, a 3-week duration of uninterrupted therapeutic anticoagulation or imaging evaluation to exclude intracardiac thrombus is recommended before elective cardioversion.1
1	B-NR	2. In patients with AF undergoing cardioversion, therapeutic anticoagulation should be established before cardioversion and continued for at least 4 weeks afterwards without interruption to prevent thromboembolism.2–7
1	C-LD	3. In patients with AF in whom cardioversion is deferred due to LAA thrombus detected on precardioversion imaging, therapeutic anticoagulation should be instituted for at least 3 to 6 weeks, after which imaging should be repeated before cardioversion.1,8
2b	B-NR	4. In patients with AF and previous LAAO who are not on anticoagulation, imaging evaluation to assess the adequacy of LAAO and exclude device-related thrombosis before cardioversion may be reasonable.9–19
2b	C-LD	5. In patients with AF and previous LAAO with residual leak, pericardioversion anticoagulation may be considered and continued thereafter.9–11,20
2b	C-LD	6. In patients with reported AF duration of <48 hours (not in the setting of cardiac surgery) and who are not on anticoagulation, precardioversion imaging to exclude intracardiac thrombus may be considered ins those who are at elevated thromboembolic risk (CHA2DS2-VASc score ≥2 or equivalent).21,22
2b	C-LD	7. In patients with low thromboembolic risks (CHA2DS2-VASc 0–1 or equivalent) and AF duration of <12 hours, the benefit of precardioversion imaging or pericardioversion anticoagulation is uncertain given the low incidence of pericardioversion thromboembolic events in this population.21,22