Chapter 10 166 benefits and risks of invasive catheter ablation. Rate control is achieved using atrioventricular blocking agents (i.e., betablockers, digoxin, verapamil) or a “pace and ablate” strategy. Rhythm control is achieved using a combination of anti-arrhythmic drugs, electrical cardioversions (ECVs), and AF catheter ablation. Inherent to every medical procedure, there are certain risks associated with electrophysiology procedures. Both ECVs and AF catheter ablation are associated with the risk of bleeding and thrombo-embolic events (2, 4, 5). In the last decade, the use of anticoagulation in patients with AF has shifted from the use of vitamin K anticoagulants (VKAs) to direct oral anticoagulants (DOACs). Several large, randomised studies (RE-LY, ROCKET-AF, ARISTOTLE and ENGAGE AF-TIMI) have demonstrated that DOACs have a more favourable risk-benefit profile regarding stroke, intracranial haemorrhage, and mortality (6). Consequently, the use of DOACs has increased considerably in patients with AF. In the Netherlands there was a slow uptake of its use before 2016, due to limited data on peri-procedural efficacy and safety, lack of an antidote, and associated increased health care costs (7, 8). Since 2016 there was a clear shift from the use of VKA to DOAC in AF patients, including patients who presented for an ECV and AF catheter ablation. In chapter 2 we evaluated thromboembolism (composite of stroke, transient ischemic attack, or systemic embolism) and major bleeding events within 60 days after ECV (9). We enrolled 920 consecutive patients undergoing an ECV comparing patients with a direct oral anticoagulants (DOAC) anticoagulation regimen to a vitamin K antagonists (VKA) regimen, without routine trans oesophageal echocardiography (TEE) between January 2013 and February 2020. There were no differences between groups regarding demographic variables and mean CHA2DS2-VASc score; however, the VKA group had a higher proportion of patients with co-morbidities. We found that in a real-world population, the rates of thromboembolism and major bleeding events were low after elective ECV in patients using DOAC or VKA and did not differ between both groups. AF catheter ablation can be associated with bleeding and thromboembolic events. In chapter 3 we evaluated 637 consecutive patients undergoing AF ablation (10). These patients had an AF catheter ablation under a VKA- or DOAC anticoagulation regimen between January 2013 and April 2017. The primary endpoints were clinically relevant
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