cardioversion with a residual thrombus is minimal. It is best to be conservative with at least three weeks of precardioversion oral anticoagulant if an atrial thrombus cannot be confidently excluded on TEE. Continuous oral anticoagulation (warfarin INR 2.0 to 3.0 or full-dose DOAC) for at least four weeks after cardioversion in all eligible patients, regardless of the cardioversion method, CHA DS -VASc score, or apparent maintenance of SR. In patients who have not achieved 2 2 therapeutic anticoagulation with warfarin at the time of cardioversion, unfractionated or low molecular weight heparin should be continued until the INR is therapeutic. Observational studies have suggested that patients with AF of more than 48 hours duration can be acutely anticoagulated with heparin/oral anticoagulant and proceed directly to cardioversion without prolonged anticoagulation if no atrial thrombus is seen on precardioversion TEE ( table 2A-B) [11,43-45]. The ACUTE trial compared a TEE-guided strategy with a conventional https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 11/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate strategy (including therapeutic warfarin [INR 2.0 to 3.0] anticoagulation for at least three weeks prior to electrical cardioversion) in 1222 patients with AF of more than two days duration (median duration 13 days) who were undergoing electrical cardioversion [12,46]. Patients assigned to the TEE-guided strategy were anticoagulated with heparin before TEE if they were inpatients or with oral warfarin for five days (target INR 2.0 to 3.0) before TEE if they were outpatients. TEE was then followed by cardioversion if no atrial thrombi were identified. With both approaches, warfarin therapy was continued for four weeks after cardioversion. If the initial TEE demonstrated thrombus (which was present in 12 percent), cardioversion was postponed and patients received therapeutic (INR 2.0 to 3.0) anticoagulation for three weeks, at which time a repeat TEE was performed. Patients assigned to conventional strategy received three weeks of therapeutic anticoagulation before cardioversion. The following findings were noted: Within the eight weeks after study enrollment, there was no significant difference between the TEE and conventional groups in the incidence of ischemic stroke (0.6 versus 0.3 percent, respectively; relative risk [RR] 1.95, 95% CI 0.36-10.60) or all embolic events, including stroke, transient ischemic attack, and peripheral embolism (0.8 versus 0.5 percent, respectively; RR 1.62, 95% CI 0.39-6.76). One important difference is that the majority of thromboembolic events in the TEE arm occurred in patients who had reverted back to AF and/or had a subtherapeutic INR at the time of the event, while the thromboembolic events in the warfarin arm occurred in patients with SR with a therapeutic INR. There were significantly fewer hemorrhagic events with the TEE strategy (2.9 versus 5.5 percent), but no significant difference in the incidence of major bleeding (0.8 versus 1.5 percent) [12,47]; in addition, there was no significant difference in all-cause mortality (2.4 versus 1 percent) or cardiac deaths (1.3 versus 0.7). The TEE strategy led to a shorter mean time to cardioversion (3 versus 31 days) and a greater incidence of successful restoration of SR (71 versus 65 percent). Thromboembolism has been reported after a negative precardioversion TEE in some patients who were not therapeutically anticoagulated at the time of TEE and continuing for one month after cardioversion [9,14,15]. These adverse events may be related to the limited sensitivity of TEE for small thrombi, or to new thrombus formation that has been reported during the period between TEE and cardioversion or after cardioversion [9,14,15]. Thus, we recommend therapeutic anticoagulation for all patients undergoing a TEE-based approach to cardioversion. https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 12/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate The development of impaired left atrial mechanical function and of new thrombi after cardioversion provides the rationale for four weeks of therapeutic anticoagulation after cardioversion (INR 2.0 to 3.0 or daily DOAC), even when the precardioversion TEE shows no thrombus [15,16]. There is suggestive evidence that such an approach reduces the incidence of embolic events [16]. (See 'Rationale for anticoagulation' above.) Although the results of the ACUTE study discussed above raise concerns about possible worse outcomes in patients treated with this strategy [39], some experts have suggested that the TEE strategy is a reasonable alternative to a conventional approach in some patients, such as those with a strong preference for early cardioversion, those with AF of less than three to four weeks duration who would benefit most from left atrial mechanical recovery, and those at increased risk of hemorrhagic complications (as the duration of precardioversion anticoagulation may be shortened). Another potential reason to consider this strategy is that a shorter period of AF may increase the likelihood of successful cardioversion and long-term maintenance of SR. (See "Atrial fibrillation: Cardioversion", section on 'Electrical cardioversion'.) RECOMMENDATIONS OF OTHERS Our recommendations are in broad agreement with those from the American Heart Association/American College of Cardiology/Heart Rhythm Society, the European Society of Cardiology, and the European Heart Rhythm Association [20,25,48,49]. SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Atrial fibrillation" and "Society guideline links: Arrhythmias in adults".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 13/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Beyond the Basics topic (see "Patient education: Atrial fibrillation (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Conversion of atrial fibrillation (AF) to sinus rhythm (SR), either spontaneously or intended, is associated with a clinically important transient increase in the risk of thromboembolism, particularly stroke. This risk increases significantly after 48 hours of AF and can be lowered by therapeutic anticoagulation before cardioversion. (See 'Rationale for anticoagulation' above.) The following recommendations apply to patients with AF of clearly less than 48 hours duration (See 'AF duration less than 48 hours' above.): For patients one or more high risk factors for thromboembolism (eg, prior thromboembolism, heart failure, or diabetes mellitus), we suggest deferral of cardioversion to allow for three weeks of effective therapeutic precardioversion anticoagulation rather than early cardioversion (Grade 2C). Anticoagulation with heparin or a direct-acting oral anticoagulant (DOAC) before, during, and after cardioversion along with precardioversion transesophageal echocardiography (TEE) is an alternative approach for these high-risk patients. For patients not at high risk of thromboembolism (listed in the above bulleted recommendation), we anticoagulate most patients with a CHA DS -VASc score 1 2 2 (Grade 2C). We start either DOAC or a combination of heparin and warfarin prior to cardioversion. For patients with low risk of thromboembolism (CHA DS -VASc score 0 in men, 1 in 2 2 women), our experts have differing approaches regarding postcardioversion anticoagulation, with some using four weeks of postcardioversion warfarin or DOAC anticoagulation and others not. The following recommendations apply to patients with AF of more than 48 hours duration or when the duration is unknown (see 'AF duration uncertain or 48 or more https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 14/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate hours' above): We recommend a minimum of three consecutive weeks of therapeutic anticoagulation (warfarin with an international normalized ratio [INR] greater than 2.0 or DOAC) prior to cardioversion, rather than proceeding directly to cardioversion (Grade 1B). We recommend a DOAC prior to elective cardioversion rather than warfarin irrespective of whether the anticoagulant will be given long term (Grade 1B). (See 'Anticoagulant approach' above.) For symptomatic patients in whom there is a strong preference to not delay cardioversion, or in whom there is a concern about bleeding with prolonged oral anticoagulation, or who are not likely to tolerate AF despite adequate rate slowing, a TEE strategy is a reasonable approach using therapeutic anticoagulation with heparin/warfarin or DOAC throughout the pericardioversion period. (See 'Transesophageal echocardiography-based approach' above.) We recommend therapeutic oral anticoagulation (with a DOAC or warfarin with target INR of 2.0 to 3.0) for four weeks after cardioversion in all patients, rather than discontinuing anticoagulation after cardioversion (Grade 1B). Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Berger M, Schweitzer P. Timing of thromboembolic events after electrical cardioversion of atrial fibrillation or flutter: a retrospective analysis. Am J Cardiol 1998; 82:1545. 2. Nagarakanti R, Ezekowitz MD, Oldgren J, et al. Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion. Circulation 2011; 123:131. 3. Flaker G, Lopes RD, Al-Khatib SM, et al. Efficacy and safety of apixaban in patients after cardioversion for atrial fibrillation: insights from the ARISTOTLE Trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation). J Am Coll Cardiol 2014; 63:1082. 4. Cappato R, Ezekowitz MD, Klein AL, et al. Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation. Eur Heart J 2014; 35:3346. 5. Goette A, Merino JL, Ezekowitz MD, et al. Edoxaban versus enoxaparin-warfarin in patients undergoing cardioversion of atrial fibrillation (ENSURE-AF): a randomised, open-label, phase https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 15/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate 3b trial. Lancet 2016; 388:1995. 6. Kinch JW, Davidoff R. Prevention of embolic events after cardioversion of atrial fibrillation. Current and evolving strategies. Arch Intern Med 1995; 155:1353. 7. Gentile F, Elhendy A, Khandheria BK, et al. Safety of electrical cardioversion in patients with atrial fibrillation. Mayo Clin Proc 2002; 77:897. 8. Arnold AZ, Mick MJ, Mazurek RP, et al. Role of prophylactic anticoagulation for direct current cardioversion in patients with atrial fibrillation or atrial flutter. J Am Coll Cardiol 1992; 19:851. 9. Stoddard MF, Dawkins PR, Prince CR, Longaker RA. Transesophageal echocardiographic guidance of cardioversion in patients with atrial fibrillation. Am Heart J 1995; 129:1204. 10. Stoddard MF, Dawkins PR, Prince CR, Ammash NM. Left atrial appendage thrombus is not uncommon in patients with acute atrial fibrillation and a recent embolic event: a transesophageal echocardiographic study. J Am Coll Cardiol 1995; 25:452. 11. Weigner MJ, Thomas LR, Patel U, et al. Early cardioversion of atrial fibrillation facilitated by transesophageal echocardiography: short-term safety and impact on maintenance of sinus rhythm at 1 year. Am J Med 2001; 110:694. 12. Klein AL, Grimm RA, Murray RD, et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001; 344:1411. 13. Manning WJ, Leeman DE, Gotch PJ, Come PC. Pulsed Doppler evaluation of atrial mechanical function after electrical cardioversion of atrial fibrillation. J Am Coll Cardiol 1989; 13:617. 14. Black IW, Hopkins AP, Lee LC, Walsh WF. Evaluation of transesophageal echocardiography before cardioversion of atrial fibrillation and flutter in nonanticoagulated patients. Am Heart J 1993; 126:375. 15. Black IW, Fatkin D, Sagar KB, et al. Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study. Circulation 1994; 89:2509. 16. Moreyra E, Finkelhor RS, Cebul RD. Limitations of transesophageal echocardiography in the risk assessment of patients before nonanticoagulated cardioversion from atrial fibrillation and flutter: an analysis of pooled trials. Am Heart J 1995; 129:71. 17. Israel CW, Gr nefeld G, Ehrlich JR, et al. Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: implications for optimal patient care. J Am Coll Cardiol 2004; 43:47. 18. Page RL, Wilkinson WE, Clair WK, et al. Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia. https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 16/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate Circulation 1994; 89:224. 19. Tejan-Sie SA, Murray RD, Black IW, et al. Spontaneous conversion of patients with atrial fibrillation scheduled for electrical cardioversion: an ACUTE trial ancillary study. J Am Coll Cardiol 2003; 42:1638. 20. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation 2019; 140:e125. 21. Gallagher MM, Hennessy BJ, Edvardsson N, et al. Embolic complications of direct current cardioversion of atrial arrhythmias: association with low intensity of anticoagulation at the time of cardioversion. J Am Coll Cardiol 2002; 40:926. 22. Weigner MJ, Caulfield TA, Danias PG, et al. Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting less than 48 hours. Ann Intern Med 1997; 126:615. 23. Airaksinen KE, Gr nberg T, Nuotio I, et al. Thromboembolic complications after cardioversion of acute atrial fibrillation: the FinCV (Finnish CardioVersion) study. J Am Coll Cardiol 2013; 62:1187. 24. Kleemann T, Becker T, Strauss M, et al. Prevalence of left atrial thrombus and dense spontaneous echo contrast in patients with short-term atrial fibrillation < 48 hours undergoing cardioversion: value of transesophageal echocardiography to guide cardioversion. J Am Soc Echocardiogr 2009; 22:1403. 25. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373. 26. Hansen ML, Jepsen RM, Olesen JB, et al. Thromboembolic risk in 16 274 atrial fibrillation patients undergoing direct current cardioversion with and without oral anticoagulant therapy. Europace 2015; 17:18. 27. Stellbrink C, Nixdorff U, Hofmann T, et al. Safety and efficacy of enoxaparin compared with unfractionated heparin and oral anticoagulants for prevention of thromboembolic complications in cardioversion of nonvalvular atrial fibrillation: the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial. Circulation 2004; 109:997. https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 17/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate 28. Klein AL, Jasper SE, Katz WE, et al. The use of enoxaparin compared with unfractionated heparin for short-term antithrombotic therapy in atrial fibrillation patients undergoing transoesophageal echocardiography-guided cardioversion: assessment of Cardioversion Using Transoesophageal Echocardiography (ACUTE) II randomized multicentre study. Eur Heart J 2006; 27:2858. 29. Garg A, Khunger M, Seicean S, et al. Incidence of Thromboembolic Complications Within 30 Days of Electrical Cardioversion Performed Within 48 Hours of Atrial Fibrillation Onset. JACC Clin Electrophysiol 2016; 2:487. 30. Pritchett EL. Management of atrial fibrillation. N Engl J Med 1992; 326:1264. 31. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361:1139. 32. Botkin SB, Dhanekula LS, Olshansky B. Outpatient cardioversion of atrial arrhythmias: efficacy, safety, and costs. Am Heart J 2003; 145:233. 33. Weinberg DM, Mancini J. Anticoagulation for cardioversion of atrial fibrillation. Am J Cardiol 1989; 63:745. 34. European Atrial Fibrillation Trial Study Group. Optimal oral anticoagulant therapy in patients with nonrheumatic atrial fibrillation and recent cerebral ischemia. N Engl J Med 1995; 333:5. 35. Hylek EM, Go AS, Chang Y, et al. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med 2003; 349:1019. 36. Piccini JP, Stevens SR, Lokhnygina Y, et al. Outcomes after cardioversion and atrial fibrillation ablation in patients treated with rivaroxaban and warfarin in the ROCKET AF trial. J Am Coll Cardiol 2013; 61:1998. 37. Collins LJ, Silverman DI, Douglas PS, Manning WJ. Cardioversion of nonrheumatic atrial fibrillation. Reduced thromboembolic complications with 4 weeks of precardioversion anticoagulation are related to atrial thrombus resolution. Circulation 1995; 92:160. 38. Jaber WA, Prior DL, Thamilarasan M, et al. Efficacy of anticoagulation in resolving left atrial and left atrial appendage thrombi: A transesophageal echocardiographic study. Am Heart J 2000; 140:150. 39. Silverman DI, Manning WJ. Strategies for cardioversion of atrial fibrillation time for a change? N Engl J Med 2001; 344:1468. 40. Seto TB, Taira DA, Tsevat J, Manning WJ. Cost-effectiveness of transesophageal echocardiographic-guided cardioversion: a decision analytic model for patients admitted to the hospital with atrial fibrillation. J Am Coll Cardiol 1997; 29:122. https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 18/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate 41. Sharma SP, Turagam MK, Gopinathannair R, et al. Direct Current Cardioversion of Atrial Fibrillation in Patients With Left Atrial Appendage Occlusion Devices. J Am Coll Cardiol 2019; 74:2267. 42. Jung PH, Mueller M, Schuhmann C, et al. Contrast enhanced transesophageal echocardiography in patients with atrial fibrillation referred to electrical cardioversion improves atrial thrombus detection and may reduce associated thromboembolic events. Cardiovasc Ultrasound 2013; 11:1. 43. Klein AL, Murray RD, Grimm RA. Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation. J Am Coll Cardiol 2001; 37:691. 44. Manning WJ, Silverman DI, Gordon SP, et al. Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. N Engl J Med 1993; 328:750. 45. Manning WJ, Silverman DI, Keighley CS, et al. Transesophageal echocardiographically facilitated early cardioversion from atrial fibrillation using short-term anticoagulation: final results of a prospective 4.5-year study. J Am Coll Cardiol 1995; 25:1354. 46. Klein AL, Grimm RA, Jasper SE, et al. Efficacy of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation at 6 months: a randomized controlled trial. Am Heart J 2006; 151:380. 47. Klein AL, Murray RD, Grimm RA, et al. Bleeding complications in patients with atrial fibrillation undergoing cardioversion randomized to transesophageal echocardiographically guided and conventional anticoagulation therapies. Am J Cardiol 2003; 92:161. 48. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199. 49. Heidbuchel H, Verhamme P, Alings M, et al. Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non- valvular atrial fibrillation: Executive summary. Eur Heart J 2016. Topic 906 Version 62.0 https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 19/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate GRAPHICS Clinical risk factors for stroke, transient ischemic attack, and systemic embolism in the CHA DS -VASc score 2 2 (A) The risk factor-based approach expressed as a point based scoring system, with the acronym CHA DS -VASc (NOTE: maximum score is 9 since age may contribute 0, 1, or 2 points) 2 2 CHA DS -VASc risk factor Points 2 2 Congestive heart failure +1 Signs/symptoms of heart failure or objective evidence of reduced left ventricular ejection fraction Hypertension +1 Resting blood pressure >140/90 mmHg on at least 2 occasions or current antihypertensive treatment Age 75 years or older +2 Diabetes mellitus +1 Fasting glucose >125 mg/dL (7 mmol/L) or treatment with oral hypoglycemic agent and/or insulin Previous stroke, transient ischemic attack, or thromboembolism +2 Vascular disease +1 Previous myocardial infarction, peripheral artery disease, or aortic plaque Age 65 to 74 years +1 Sex category (female) +1 (B) Adjusted stroke rate according to CHA DS -VASc score 2 2 CHA DS -VASc score Patients (n = 73,538) Stroke and thromboembolism event 2 2 rate at 1-year follow-up (%) 0 6369 0.78 1 8203 2.01 2 12,771 3.71 3 17,371 5.92 4 13,887 9.27 https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 20/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate 5 8942 15.26 6 4244 19.74 7 1420 21.50 8 285 22.38 9 46 23.64 CHA DS -VASc: Congestive heart failure, Hypertension, Age ( 75; doubled), Diabetes, Stroke (doubled), Vascular disease, Age (65 to 74), Sex. 2 2 Part A from: Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial brillation developed in collaboration with EACTS. Europace 2016; 18(11):1609-1678. By permission of Oxford University Press on behalf of the European Society of Cardiology. Copyright 2016 Oxford University Press. Available at: www.escardio.org/. Graphic 83272 Version 29.0 https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 21/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate Optimal INR to minimize both bleeding and thromboembo lism in patients with atrial fibrillation (A) ORs for TE (396 cases, 1581 controls) and ICH (164 cases, 656 controls) by INR level in adults with nonvalvular AF, with 8 INR categories using INR 2.0 to 2.5 as the referent. Vertical bars indicate 95% CI. The numbers of cases and controls for each INR category are given below the figure. (B) ORs for TE (396 cases, 1581 controls) and ICH (164 cases, 656 controls) by INR level in adults with nonvalvular AF, with 6 INR categories using INR 2.0 to https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 22/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate 2.5 as the referent. Vertical bars indicate 95% CI. The numbers of cases and controls for each INR category are given below the figure. AF: atrial fibrillation; INR: international normalized ratio; OR: odds ratio; TE: thromboembolism; ICH: intracranial hemorrhage; CI: confidence interval. Reproduced with permission from: Singer DE, Chang Y, Fang MC, et al. Should patient characteristics in uence target anticoagulation intensity for stroke prevention in nonvalvular atrial brillation? The ATRIA study. Circ Cardiovasc Qual Outcomes 2009; 2:297. Copyright 2009 Lippincott Williams & Wilkins. Graphic 65373 Version 13.0 https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 23/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate Odds ratios for ischemic stroke and intracranial bleeding in relation to intensity of anticoagulation Adjusted odds ratios for ischemic stroke and intracranial bleeding in relation to intensity of anticoagulation. Reproduced with permission from: Fuster V, Ryden LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial brillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2011; 123:e269. Copyright 2011 Lippincott Williams & Wilkins. Graphic 87025 Version 4.0 https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 24/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate Advantages and disadvantages of the conventional approach to cardioversion (one month of pretreatment with warfarin) in patients with atrial fibrillation Advantages Disadvantages Use of warfarin for one month before Delaying cardioversion to normal sinus rhythm for one cardioversion may lower the stroke rate month potentially decreases functional capacity. from 5.6 percent to a very low stroke rate of <2 percent. Relatively easy to administer with regular Prolonging treatment for seven to eight weeks one monitoring of INRs. month prior to and one month after cardioversion increases the risk of bleeding complications. Suitable for community hospitals. Not followed by routine clinical practice, especially in the elderly. The conventional approach has withstood the "test of time" since the 1960s. Patients who are at the highest risk for developing systemic embolization who should receive more prolonged or intensive anticoagulation are not routinely identified. Reprinted with permission from the American College of Cardiology. J Am Coll Cardiol 2001; 37:691. https://www.journals.elsevier.com/journal-of-the-american-college-of-cardiology. Graphic 72971 Version 6.0 https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 25/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate Advantages and disadvantages of the transesophageal echocardiography- guided approach to cardioversion of patients with atrial fibrillation undergoing cardioversion Advantages Disadvantages Transesophageal echocardiography (TEE) should be able to detect left atrial appendage thrombi, TEE is performed without any definitive guidelines about who should receive the which increase the risk of embolic stroke after procedure (high versus low risk) electrical cardioversion, thus sparing patients with thrombi from undergoing cardioversion In the majority of patients without left atrial Residual thrombus on repeat TEE may diminish appendage thrombi, earlier cardioversion may shorten the period of anticoagulation and lower the cost-effectiveness of the TEE-guided approach the corresponding risk of bleeding complications A TEE-guided approach may prove more cost- effective owing to the reduction in laboratory Transesophageal echocardiography requires a level III-trained physician and availability of monitoring costs and the reduction in bleeding complications expensive echocardiographic machines Earlier cardioversion is believed to increase the Transesophageal echocardiography may miss likelihood of a successful return to and thrombi that may embolize after cardioversion. In maintenance of sinus rhythm contrast, TEE may render false positive results by erroneously identifying spontaneous echocardiographic contrast, sludge, multilobed appendages or pectinate muscles as thrombus. Reprinted with permission from: The American College of Cardiology. J Am Coll of Cardiol 2001; 37:691-704. https://www.journals.elsevier.com/journal-of-the-american-college-of-cardiology. Graphic 54077 Version 6.0 https://www.uptodate.com/contents/prevention-of-embolization-prior-to-and-after-restoration-of-sinus-rhythm-in-atrial-fibrillation/print 26/27 7/6/23, 12:53 PM Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation - UpToDate Contributor Disclosures Robert Phang, MD, FACC, FHRS No relevant financial relationship(s) with ineligible companies to disclose. Warren J Manning, MD Equity Ownership/Stock Options: Pfizer [Anticoagulants]. All of the relevant financial relationships listed have been mitigated. Bradley P Knight, MD, FACC Grant/Research/Clinical Trial Support: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; MDT [Electrophysiology]; Philips [Electrophysiology]. Consultant/Advisory Boards: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; CVRx [Heart failure]; MDT [Electrophysiology]; Philips [Electrophysiology]; Sanofi [Arrhythmias]. Speaker's Bureau: Abbott [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Transeptal catheterization]; BSCI [Electrophysiology]; MDT [Electrophysiology]. All of the relevant financial relationships listed have been mitigated. Brian Olshansky, MD Other Financial Interest: AstraZeneca [Member of the DSMB for the DIALYZE trial]; Medtelligence [Cardiovascular disease]. All of the relevant financial relationships listed have been mitigated. N A Mark Estes, III, MD Consultant/Advisory Boards: Boston Scientific [Arrhythmias]; Medtronic [Arrhythmias]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. 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