First, recurrence of AF at 1 year after cardioversion occurs in approximately one- half of patients, and therefore long-term stroke risk is Second, the Atrial Fibrillation Follow- up Investigation of Sinus Rhythm Management (AFFIRM) study, in which many patients stopped anticoagulation after initial (apparently) successful restoration of sinus rhythm, demonstrated similar rates of thromboembolism with a rhythm control strategy compared with a rate control strategy.262 Third, patients with paroxysmal AF are often asymptomatic during episodes of AF recurrence, with 1 series suggesting that only 1 in every 12 paroxysms are symptomatic.263 Recommendation 12. For patients with AF of greater than 48 h or unknown duration undergoing elective electrical or pharmacologic cardioversion, we recommend therapeutic anticoagulation with well-managed VKA (INR 2-3) or an NOAC using dabigatran, rivaroxaban, edoxaban, or apixaban for at least 3 weeks before cardioversion or a transesophageal echocardiography (TEE)-guided approach with abbreviated anticoagulation before cardioversion rather than no anticoagulation (Strong recommendation, moderate quality evidence). Remark: With NOACs adherence and persistence should be strongly emphasized. 13. For patients with AF of greater than 48 h or unknown duration undergoing elective electrical or pharmacologic cardioversion, we recommend therapeutic anticoagulation (with VKA or NOAC) for at least 4 weeks after successful cardioversion to sinus rhythm rather than no anticoagulation, regardless of the baseline risk of stroke (Strong recommendation, moderate quality evidence). Remark: Decisions about anticoagulation beyond 4 weeks should be made in accordance with our risk- based recommendations for long-term antithrombotic therapy in recommendations 1 and 2, and not on the basis of successful cardioversion. 14. In patients in which LAA thrombus is detected on TEE, cardioversion postponed, and OAC continued for another 4-12 weeks, to allow thrombus resolution or endothelization, we suggest that a decision on whether a repeat TEE is performed should be individualized (Ungraded consensus-based statement). 