An existing systematic review from Renda et al239 compared the use of NOAC vs VKA in the setting of cardioversion in 6 studies. Reported pooled RRs (relative risk reductions) were 0.82 (0.38-1.75) for stroke/systemic embolism, 0.72 (0.27-1.90) for mortality, and 0.72 (0.19-2.71) for MI, respectively, suggesting at least comparable ef cacy of NOACs with VKA in the setting of cardioversion (e-Table 17). It should be noted that despite these reassuring data, the included trials were underpowered for safety and ef cacy, and judged to be of poor quality. The need for consensus guidance is illustrated by the current wide variation in VKA and NOAC use in the setting of elective cardioversion.240,241 Available data support the use of rivaroxaban,242,243 in patients to be continued on these NOACs if scheduled for cardioversion. Similar observations were found in a randomized trial of apixaban vs warfarin (Eliquis Evaluated in Acute Cardioversion Compared to Usual Treatments for Anticoagulation in Subjects With Atrial A TEE-guided approach with abbreviated anticoagulation before cardioversion has been recommended as an alternative to the conventional approach of using a minimum of 3 weeks therapeutic pre-cardioversion anticoagulation as outlined above.248 In the TEE-guided strategy, patients receive VKA and once therapeutic, undergo a screening TEE. If the TEE identi es thrombus in either the atrial appendage or atrium, cardioversion is postponed, given the presumed high risk of thromboembolism. In the absence of thrombus, cardioversion is immediately performed. Given the need for accurate visualization of thrombus, the TEE-guided strategy requires an experienced 1164 Evidence-Based Medicine [ 1 5 4 # 5 C H E S T N O V E M B E R 2 0 1 8 ] echocardiographer. 