A few observational studies and one RCT have suggested that low-molecular-weight heparin has similar ef cacy compared with heparin or warfarin for immediate anticoagulation before TEE.146-150 Out- patients undergoing a TEE-guided approach may be started on a VKA (INR 2.5; range, 2.0-3.0) and the TEE and subsequent cardioversion scheduled for 5 days later (if the INR is in therapeutic range at that time). The new oral anticoagulants may also be suitable for outpatient treatment before TEE-guided cardioversion given their ease of use (eg, dabigatran achieves steady-state concentrations in 2-3 days after bid administration),151 but they have not yet been studied for this purpose. There is no direct evidence to guide decisions about the long-term management of anticoagula- tion in patients who appear to be in sinus rhythm 4 weeks after cardioversion. Several observational studies indicate that approximately one-half of patients will have recurrence of AF at 1 year after cardioversion.152-156 The AFFIRM study, in which many patients stopped anticoagulation after initial (apparently) successful restoration of sinus rhythm, found similar rates of thromboembolism with a rhythm control strategy compared with a rate con- trol strategy.125 Finally, patients with PAF often are asymptomatic during episodes of AF recurrence, with one series suggesting that only one in every 12 paroxysms are symptomatic.157 These observations suggest that decisions about long-term antithrom- botic therapy should be primarily based on a patient s risk for stroke (see section 2.1) rather than on the prevailing rhythm at 4 weeks postcardioversion. Recommendation 4.1.1. 