What is the recommendation for patients with AF of greater than 48 hours or unknown duration undergoing elective electrical or pharmacologic cardioversion?
For patients with AF of greater than 48 hours or unknown duration undergoing elective electrical or pharmacologic cardioversion, the recommendation is to use therapeutic anticoagulation with well-managed VKA (INR 2-3) or an NOAC using dabigatran, rivaroxaban, edoxaban, or apixaban for at least 3 weeks before cardioversion or a transesophageal echocardiography (TEE)-guided approach with abbreviated anticoagulation before cardioversion rather than no anticoagulation. After successful cardioversion, therapeutic anticoagulation (with VKA or NOAC) should be used for at least 4 weeks. Decisions about anticoagulation beyond 4 weeks should be made in accordance with risk- based recommendations for long-term antithrombotic therapy.