Do I need to continue taking anticoagulation medication (e.g. apixaban, rivaroxaban, warfarin) if I haven't had an episode of atrial fibrillation (AFib) in a while and my electrocardiogram (EKG) results don't show AFib?

Anticoagulation Should Continue Based on Your Stroke Risk, Not Current AFib Presence

You need to continue anticoagulation if you have risk factors for stroke (assessed by CHA₂DS₂-VASc score), regardless of whether AFib is currently detected on EKG or how long it has been since your last episode. 1

The Critical Principle: Stroke Risk Drives Anticoagulation, Not AFib Frequency

• Anticoagulation decisions must be based on your stroke risk factors (age, hypertension, diabetes, prior stroke, heart failure, vascular disease), not on whether AFib is currently visible on EKG or how often episodes occur. 1

• The presence or absence of symptoms and the pattern of AFib (paroxysmal, persistent, or permanent) should NOT influence whether you need anticoagulation—only your stroke risk matters. 1

• Even if you haven't had AFib episodes in a while, the stroke risk associated with your underlying conditions persists. 1

Understanding Your Stroke Risk: The CHA₂DS₂-VASc Score

Your need for anticoagulation depends on calculating your CHA₂DS₂-VASc score, which includes: 1

• Congestive heart failure (1 point)
• Hypertension (1 point)
• Age ≥75 years (2 points)
• Diabetes (1 point)
• Prior Stroke/TIA (2 points)
• Vascular disease (coronary artery disease, peripheral artery disease, aortic plaque) (1 point)
• Age 65-74 years (1 point)
• Female sex (1 point)

Anticoagulation Recommendations Based on Score:

• Score of 0 (men) or 1 (women): You can reasonably omit anticoagulation 1, 2
• Score of 1 (men): Either anticoagulation or no treatment may be considered 1
• Score ≥2 (men) or ≥3 (women): Anticoagulation is strongly recommended 1

Confirming Your AFib Diagnosis

Before making any changes, you need definitive confirmation: 1

• A clinically documented episode of AFib on 12-lead EKG or validated rhythm monitoring device is required for diagnosis. 1

• If you only have device-detected atrial high-rate episodes (AHRE) from implanted cardiac devices lasting ≥5 minutes, the actual electrograms must be reviewed to exclude artifacts before confirming AFib. 1

• Simply having "notes" about possible AFib without actual EKG documentation showing the characteristic irregularly irregular rhythm is insufficient for diagnosis. 1

What You Should Do Now

Step 1: Obtain documentation of your AFib diagnosis 1

• Request copies of all EKGs showing AFib
• If no documented AFib exists on 12-lead EKG, you may not have a confirmed diagnosis requiring anticoagulation

Step 2: Calculate your CHA₂DS₂-VASc score with your physician 1

• If your score is ≥2 (men) or ≥3 (women) AND you have documented AFib, continue anticoagulation
• If your score is 0 (men) or 1 (women), you can reasonably stop anticoagulation 1, 2

Step 3: If AFib is confirmed but you're uncertain about continuing anticoagulation 1

• The decision should weigh your absolute stroke risk against bleeding risk
• However, bleeding risk scores should identify modifiable risk factors to address, NOT be used as reasons to withhold anticoagulation 2

Common Pitfall to Avoid

Do not assume that absence of recent AFib episodes or normal recent EKGs means you can stop anticoagulation. The relationship between AFib and stroke is complex—stroke can occur without concurrent AFib at the time of the event, suggesting AFib may be a marker of underlying vascular risk rather than always the direct cause. 1 Once you have documented AFib with elevated stroke risk, anticoagulation should continue indefinitely based on your CHA₂DS₂-VASc score, not rhythm status. 1