Practical Issues With VKA and NOAC Cardioversion Antithrombotic Therapy for Patients With AF Undergoing Cardioversion: In AF of documented short duration (ie, # 48 h), urgent cardioversion commonly occurs without prolonged pre-cardioversion anticoagulation. In the context of elective cardioversion, whether electrical or chemical, therapeutic anticoagulation either with adjusted-dose VKAs, or NOACs is currently recommended for a minimum of 3 weeks before, and for a minimum of 4 weeks after, the procedure. In AF of > 48 h duration or unknown duration, a TEE-guided approach provides an alternative strategy to guide anticoagulation management before cardioversion. In this section, we appraise and summarize the evidence and give recommendations for the use of antithrombotic therapy in patients undergoing electrical or pharmacologic cardioversion for AF (or atrial utter). In particular, the option of NOACs in the setting of cardioversion is reviewed. Cardioversion of AF of > 48 h or Unknown Duration VKA: Observational data support the use of VKA in the context of elective cardioversion, whether electrical or pharmacologic. A systematic review of 18 observational studies provides moderate-quality evidence for a lower risk of stroke or thromboembolism with peri- cardioversion anticoagulation (with VKA) vs no 0.48), but did not report major bleeding events.233 The recommended duration of a minimum of 3 weeks therapeutic anticoagulation with VKA before cardioversion and a minimum 4 weeks subsequently is arbitrary and has no trial basis, being based on indirect pathophysiological and observational data. 