We recommend for patients with acute hemodynamic instability secondary to rapid recent-onset AF/AFL, immediate electrical conversion to sinus rhythm. (Recommendation Strong, Quality Low)<br /><br /><b>Values and preferences: </b> This recommendation places a high value on the immediate management of hemodynamic instability and a lower value on anticoagulation status under these circumstances. It is also recognized that this is a relatively rare circumstance and that, in most cases, stroke risk and anticoagulation status can be considered prior to immediate cardioversion.