For patients with AF of documented duration of 48 h or less undergoing elective cardioversion (electrical or pharmacologic), we suggest starting anticoagulation at presentation (low-molecular- weight heparin or unfractionated heparin at full venous thromboembolism treatment doses) and proceeding to cardioversion rather than delaying cardioversion for 3 weeks of therapeutic anticoagulation or a TEE-guided approach (Weak recommendation, low quality evidence). *16. For patients with AF and hemodynamic instability undergoing urgent cardioversion (electrical or pharmacologic), after successful cardioversion to sinus rhythm, we recommend therapeutic anticoagulation (with VKA or full adherence to NOAC therapy) for at least 4 weeks rather than no anticoagulation, regardless of baseline stroke risk (Weak recommendation, low quality evidence). Remark: Decisions about long-term anticoagulation after cardioversion should be made in accordance with our risk-based recommendations for long-term antithrombotic therapy in recommendations 1 and 2. 1166 Evidence-Based Medicine [ 1 5 4 # 5 C H E S T N O V E M B E R 2 0 1 8 ] Patients Undergoing Urgent Cardioversion for Hemodynamically Unstable AF: Our systematic review of anticoagulation vs no anticoagulation in patients with AF undergoing urgent cardioversion found no published data regarding the optimal anticoagulation strategy to use before or during urgent cardioversion for patients with AF and hemodynamic instability. On the basis of the above evidence for anticoagulation in elective cardioversion, initiation of anticoagulation immediately before urgent cardioversion (eg, with UFH or LMWH) would be expected to reduce the risk of stroke/thromboembolism based on studies of elective cardioversion. Initiation of anticoagulation therapy should not delay any emergency interventions required in order to stabilize the patient. Recommendations *17. 