We suggest that patients at high risk of stroke (not receiving therapeutic OAC therapy for ≥3 weeks with any of the following: AF episode duration not clearly <48 hours; stroke or TIA within 6 months; rheumatic heart disease; mechanical valve) may undergo cardioversion guided by transesophageal echocardiography with immediate initiation of intravenous or low molecular weight heparin prior to cardioversion followed by therapeutic OAC for at least 4 weeks post cardioversion. (Conditional Recommendation, Moderate Quality Evidence)

Practical Tip: If a NOAC is not used post-TEE guided cardioversion, heparin bridging should be started immediately while warfarin is initiated.