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8.2.1. Prevention of Thromboembolism in the Setting of
Cardioversion
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 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.
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.
2b B-NR 4. In patients with AF and prior LAAO who are not on
anticoagulation, imaging evaluation to assess the adequacy
of LAAO and exclude device-related thrombosis before
cardioversion may be reasonable.
2b C-LD 5. In patients with AF and prior LAAO with residual leak,
pericardioversion anticoagulation may be considered and
continued thereafter.
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 in those who are at
elevated thromboembolic risk (CHA
2
DS
2
-VASc score ≥2 or
equivalent).
2b C-LD 7. In patients with low thromboembolic risks (CHA
2
DS
2
-
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.
8.2. Electrical and Pharmacological Cardioversion
