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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e69 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation improved QOL indices in all patients, but 24% to 34% of patients developed symptoms mainly due to AT after the ablation procedure.53,54 7 AF is associated with increased cognitive impair- ment, progressive increase in AF burden, and structural changes in the heart.33,34 Nonrandomized studies from registries or post hoc analyses of randomized trials have reported that rhythm control is associated with a reduction in the incidence of dementia and development of HF.36–38 Furthermore, AF can also be an etiologic reason for mitral regurgitation or tricuspid regurgitation.39–45 In 1 study of 53 patients referred for AF ablation with moderate mitral regurgitation or worse, maintenance of sinus rhythm at follow-up was associated with significant decreases in LA size, mitral annular dilatation, and mitral regurgitation.39 In another study, 70% of patients undergoing ablation for AF who maintained sinus rhythm at follow-up had improvement in mitral regurgitation.40 Similar results have been found in tricuspid valve function as assessed by echocardiography.42–45 8.2 Electrical and Pharmacological Cardioversion Cardioversion to restore sinus rhythm is a mode of acute rhythm control. Cardioversion can be achieved electrically or pharmacologically. Electrical cardioversion, given rapidity and efficacy, is the treatment of choice for patients with hemodynamic instability attributable to AF. Acute rhythm control with cardioversion should also be considered for patients with hemodynamically stable AF intolerant of atrioventricular dyssynchrony, loss of atrial kick, or unable to achieve adequate rate control. In patients with hemodynamically stable AF, both electrical cardioversion and pharmacological cardioversion are acceptable, safe, and efficacious methods for acute rhythm control.1–3 Electrical cardioversion is more effective than pharmacological cardioversion alone4,5 but involves the trade-off of anesthesia or sedation.6 Thromboembolic risks and considerations for anticoagulation apply to both pharmacological cardioversion and electrical cardioversion.7,8 8.2.1 Prevention of Thromboembolism in the Setting of Cardioversion 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, thera- peutic 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 Synopsis Thromboembolic risks and considerations of anticoagulation apply to both pharmacological cardioversion and electrical cardioversion.23,24 Thromboembolic risks in the setting of acute cardioversion relate to preexisting thrombus, change in atrial mechanical function with restoration of sinus rhythm, atrial stunning postcardioversion, and transient prothrombotic state.2,25 DOACs are alternatives to VKAs as thromboprophylaxis in the setting of cardioversion.26–29 Given additional favorable attributes of rapid time to therapeutic efficacy, reliability of maintenance of therapeutic efficacy, and ease of continuation, DOACs may be preferentially considered over VKAs for patients with AF planned for cardioversion barring contraindications to DOAC therapy. Precardioversion imaging is prudent for patients with AF who have previously undergone LAAO and are not on anticoagulation.9,10,14–16,19 Thromboembolic risks for patients with <48 hours of AF were not homogenous but, rather, varied by a patient’s risk profile for thromboembolic complications (as defined by risk scores in specific studies) and duration of AF.21,22 More nuanced consideration of a patient’s thromboembolic risks in the setting of cardioversion for AF may integrate a patient’s substrate for atrial myopathy and risks for thromboembolism instead of strict dependence on the previously used 48-hour duration threshold. Recommendations for Prevention of Thromboembolism in the Setting of Cardioversion (Continued ) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026