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. The rationale for maintenance of a therapeutic INR in the peri- cardioversion period is from observational data, showing that thromboembolism is signi cantly more common at INR of 1.5 to 2.4 before cardioversion than INR of 2.5 Retrospective observational studies suggest that, after cardioversion, the highest risk of stroke and thromboembolism is in the rst 72 h. In addition, most thromboembolic complications are within However, even if sinus rhythm is restored on ECG, TEE studies have shown that atrial mechanical dysfunction can persist for several weeks Recent Finnish registry data suggest that most post-cardioversion strokes are associated with not using anticoagulation.237 Although data relating to the impact of long-term anticoagulation post-cardioversion are lacking, relevant Swedish observational data suggest that discontinuation of warfarin after catheter ablation is not safe in high-risk patients, especially those individuals with a history of It is also worth noting that although the risk of ischemic stroke/thromboembolism is higher with non-paroxysmal vs paroxysmal AF (multivariable adjusted HR, 1.38; 95% CI, 1.19-1.61; P < .001), the pattern of AF does not affect the decision regarding long-term OAC. NOACs: Evidence is available for all 4 currently available NOACs: dabigatran, apixaban, rivaroxaban, and edoxaban. An existing systematic review from Renda et al239 compared the use of NOAC vs VKA in the setting of cardioversion in 6 studies. 