OBJECTIVES: Electrical cardioversion (ECV) is a procedure in which a direct-current electric shock is used to, quickly and effectively restore the normal sinus rhythm. Appropriate anticoagulation reduces the risk of embolic events during and after the ECV procedure. The aim of this study is to estimate the cost-effectiveness of rivaroxaban compared to a vitamin K oral antagonist (VKA) in patients with atrial fibrillation (AF) undergoing elective ECV in the Netherlands. METHODS: A static transmission model over a one year time-horizon was developed to compare rivaroxaban to VKAs in terms of clinical outcomes, health effects and costs. The clinical outcomes were AF-related events, such as stroke and hemorrhages. Costs were assessed from a societal perspective, also accounting for indirect costs due to productivity losses and informal care. The final outcomes were incremental costs and quality-adjusted life years (QALYs). Cost-effectiveness was assessed at a willingness-to-pay (WTP) of €20,000/QALY gained. RESULTS: The use of rivaroxaban as an anticoagulant in patients with AF scheduled for ECV would lead to a health gain of 0.23 QALY per patient and would cost €1.83 per patient from the societal perspective resulting in an incremental cost-effectiveness ratio (ICER) of €7.92/QALY gained. The probability of rivaroxaban being cost saving was 49.6% compared to VKAs from this perspective. From the health care payer perspective, total costs would be €509 per patient with a health gain of 0.23 QALY per patient resulting in an ICER of €2,198/ QALY gained. CONCLUSIONS: The use of rivaroxaban in elective electrical cardioversion is a cost-effective alternative for VKAs. Rivaroxaban has almost a 50% probability to be cost-saving and would increase a patients’ quality of life when taking into account non-healthcare costs such as productivity loss and informal care costs.