Should Eliquis (apixaban) be held before cardioversion?

Anticoagulation Management for Cardioversion with Eliquis (Apixaban)

Eliquis (apixaban) should not be held before cardioversion for atrial fibrillation. 1

General Principles for Anticoagulation with Cardioversion

For AF Duration >48 Hours or Unknown Duration

• Therapeutic anticoagulation with Eliquis should be continued for at least 3 weeks before and 4 weeks after cardioversion 1
• This recommendation applies to both electrical and pharmacological cardioversion 1
• NOACs like apixaban are considered effective and safe alternatives to warfarin for patients undergoing cardioversion 1

For AF Duration <48 Hours

• For patients with CHA₂DS₂-VASc score ≥2 in men or ≥3 in women, anticoagulation with apixaban should be administered before cardioversion and continued afterward 1
• For patients with CHA₂DS₂-VASc score of 0 in men or 1 in women with AF <48 hours, anticoagulation may be considered before cardioversion without the need for post-cardioversion oral anticoagulation 1

For Emergency Cardioversion

• In patients requiring immediate cardioversion due to hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after the procedure 1
• Initiation of anticoagulation should not delay emergency intervention 1

TEE-Guided Approach

• For patients with AF >48 hours who have not been anticoagulated for the preceding 3 weeks, a TEE-guided approach is reasonable 1
• If no left atrial thrombus is identified, cardioversion can proceed with anticoagulation maintained for at least 4 weeks afterward 1
• This approach saves time before cardioversion but requires proper anticoagulation before and after the procedure 1

Long-Term Anticoagulation Decisions

• The decision about continuing anticoagulation beyond 4 weeks should be based on the patient's thromboembolic risk profile (CHA₂DS₂-VASc score) and bleeding risk profile, not on the success of cardioversion 1
• Even after successful cardioversion, patients with risk factors for stroke should continue long-term anticoagulation 1

Rationale and Mechanism

• Cardioversion can cause transient mechanical dysfunction of the left atrium ("stunning"), which may lead to thrombus formation even after successful restoration of sinus rhythm 1
• This explains why thromboembolic events often occur within 10 days after cardioversion 1
• Continuous anticoagulation through the cardioversion period protects against these events 1

Common Pitfalls to Avoid

• Discontinuing anticoagulation immediately after successful cardioversion (should continue for at least 4 weeks) 1
• Delaying emergency cardioversion to achieve therapeutic anticoagulation in hemodynamically unstable patients 1
• Failing to overlap parenteral and oral anticoagulation when transitioning between agents 2
• Assuming atrial flutter carries no risk of thromboembolism (it does, and requires the same anticoagulation approach as AF) 1

Summary

Eliquis should be continued without interruption when performing cardioversion for atrial fibrillation. The duration of pre- and post-cardioversion anticoagulation depends on the duration of AF and patient-specific risk factors, but generally should be maintained for at least 4 weeks after the procedure, with long-term decisions based on stroke and bleeding risk profiles.