The Living Guidelines: Prevention of thromboembolism in patients with atrial fibrillation undergoing cardioversion: Suggest Revisions to the CLASS IIa Guidelines

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Class IIa Guidelines
1. During the first 48 h after onset of AF, the need for anticoagulation before and after cardioversion may be based on the patient’s risk of thromboembolism. (Level of Evidence: C)

2. As an alternative to anticoagulation prior to cardioversion of AF, it is reasonable to perform TEE in search of thrombus in the LA or LAA. (Level of Evidence: B)


 * 2a. For patients with no identifiable thrombus, cardioversion is reasonable immediately after anticoagulation with unfractionated heparin (e.g., initiate by intravenous bolus injection and an infusion continued at a dose adjusted to prolong the activated partial thromboplastin time to 1.5 to 2 times the control value until oral anticoagulation has been established with a vitamin K antagonist (e.g., warfarin), as evidenced by an INR equal to or greater than 2.0.). (Level of Evidence: B) Thereafter, oral anticoagulation (INR 2.0 to 3.0) is reasonable for a total anticoagulation period of at least 4 wk, as for patients undergoing elective cardioversion. (Level of Evidence: B) Limited data are available to support the subcutaneous administration of a low molecular weight heparin in this indication. (Level of Evidence: C)


 * 2b. For patients in whom thrombus is identified by TEE, oral anticoagulation (INR 2.0 to 3.0) is reasonable for at least 3 week prior to and 4 week after restoration of sinus rhythm, and a longer period of anticoagulation may be appropriate even after apparently successful cardioversion, because the risk of thromboembolism often remains elevated in such cases. (Level of Evidence: C)

3. For patients with atrial flutter undergoing cardioversion, anticoagulation can be beneficial according to the recommendations as for patients with AF. (Level of Evidence: C)