Short-Term Anticoagulation After Cardioversion in New-Onset Atrial Fibrillation and Low Thromboembolic Risk: A Real-World International Investigation

<i>Background and Objectives</i>: International guidelines differ on short-term (4-week) oral anticoagulation (OAC) indication after acute cardioversion for recent-onset atrial fibrillation (AF < 12-48 h) in low-risk patients (CHA₂DS₂-VA = 0). While Canadian and Chinese guidelines recommend OAC for all, European, Australian and New Zealand, and American guidelines state that such treatment is optional due to the absence of high-quality evidence supporting its indication in this specific scenario. This study aimed to assess physicians' management of a simple clinical case at an international level, focusing on how they balance ischemic and bleeding risks in a setting lacking any strong evidence-based recommendations. <i>Materials and Methods</i>: Six different AF guidelines were evaluated regarding the recommendation for and scientific evidence justifying short-term OAC in this specific setting. Following review, an international questionnaire was developed with <i>Google Forms 2024</i> (Mountain View, CA, USA) and circulated among physicians working in the fields of cardiology, internal medicine, intensive care unit, geriatrics, and emergency medicine at 17 centres in Italy, France, and Canada. <i>Results</i>: A total of 78 responses were obtained. Younger physicians and cardiologists appeared to administer OAC more frequently compared to older physicians or those working in other specialties (95% CI Fisher's Exact Test <i>p</i> = 0.049 and 0.029, respectively). Significant differences were observed in the use of periprocedural imaging, with transoesophageal echocardiogram (TOE) prior to cardioversion being performed more often in Europe vs. Canada (<i>p</i> = 0.006) and in long-term rhythm control, with first-line pulmonary vein isolation (PVI) being offered more frequently by European cardiologists (<i>p</i> = 0.013). No statistically significant association was found regarding guideline adherence for OAC administration (<i>p</i> = 0.120). <i>Conclusions</i>: The real-world antithrombotic management of low-risk (CHA₂DS₂-VA = 0), acutely cardioverted AF patients varies significantly among different healthcare systems. Particularly in cardiology departments, reducing the time limit for safely not prescribing OAC to < 12 h, ensuring local access to direct oral anticoagulants (DOACs) and considering regional stroke risk profiles, as well as actively preventing haemorrhage in patients receiving short-term OAC could all limit cardioversion-related complications in this low-risk population.