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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e70 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation Recommendation-Specific Supportive Text 1. Early experience with both pharmacological and then electrical cardioversion of AF led to the observation that thromboembolism was less frequent in patients who were chronically anticoagulated than those who were not.30 This led to an empiric recommendation for 3 weeks of anticoagulation before cardioversion in the prospective, randomized, multicenter ACUTE (Assessment of Cardioversion Using Tranesophageal Echocardiography) study of patients with >2 days’ duration of AF.31 Precardioversion anticoagulation of at least 3 weeks may be accomplished via either therapeutic anticoagulation with VKAs or DOACs.26–28 Cardiac computed tomography, particularly with delayed contrast-enhanced image acquisition protocol, has emerged as an alternate imaging modality to exclude intracardiac thrombus.32–34 2 Rationales for establishment of therapeutic anti- coagulation before cardioversion and continuation for the subsequent 4 weeks after cardioversion for AF are driven by elevated thromboembolic risks,6,7,35 high early recurrence of AF,36 and observation of atrial dysfunction2–5 during this period. Thromboembolic risks are elevated around the time of cardioversion, especially within the 30 days after cardioversion.6,7 The observation of spontaneous echocardiographic contrast in association with atrial dysfunction on TEE after cardioversion raised mechanistic concerns for atrial stunning in the setting of cardioversion,2,3 with recovery of mechanical atrial systole over the ensuing 1 month.4,5 Rapidity of recovery of mechanical atrial systole may be influenced by clinical variables,37 duration of the antecedent AF episode leading to cardioversion,5 Figure 21. Patients With Hemodynamically Stable AF Planned for Cardioversion. Colors correspond to Table 2. AC indicates anticoagulation; AF, atrial fibrillation; and LAAO, left atrial appendage occlusion. Downloaded from http://ahajournals.org by on October 7, 2026