Can I stop taking apixaban (eliquis) if I've never been diagnosed with atrial fibrillation?

Can You Stop Taking Apixaban Without a Confirmed Atrial Fibrillation Diagnosis?

Yes, you can discontinue apixaban if you have never been diagnosed with atrial fibrillation, as anticoagulation is only indicated when AF has been documented, and your extensive cardiac monitoring (3-year implantable monitor plus two ablations) never captured AF. 1

Evidence Supporting Discontinuation

Indication Requirements for Anticoagulation

• Anticoagulation with apixaban or other oral anticoagulants is specifically recommended for patients WITH documented atrial fibrillation who have stroke risk factors (CHA₂DS₂-VASc score ≥1 in males or ≥2 in females). 1

• The 2012 European Society of Cardiology guidelines explicitly state that NOACs like apixaban are recommended for "patients with AF" and "non-valvular AF," requiring documented arrhythmia as the foundation for anticoagulation therapy. 1

• Your situation is unique: despite 3 years of continuous cardiac monitoring with an implantable device (the gold standard for detecting paroxysmal AF) and two electrophysiology studies with ablation attempts, no atrial fibrillation was ever documented. 1

What Was Actually Found and Treated

• Your ablations successfully targeted and treated SVT (supraventricular tachycardia), not atrial fibrillation. SVT and AF are distinct arrhythmias with different stroke risk profiles. 1

• SVT alone, without documented AF, does not carry the same thromboembolic risk that mandates anticoagulation. 1

• The fact that electrophysiologists could not induce AF during two separate ablation procedures further supports that you do not have inducible or sustained AF. 1

Clinical Reasoning for Stopping Apixaban

Risk-Benefit Analysis

• Continuing anticoagulation without a documented indication exposes you to bleeding risk (1.4% per year major bleeding with apixaban) without the corresponding stroke prevention benefit that only applies to patients with confirmed AF. 2, 3

• The ARISTOTLE trial, which established apixaban's efficacy, enrolled only patients with documented atrial fibrillation—your clinical scenario falls outside this evidence base. 4, 2

Monitoring Adequacy

• A 3-year implantable cardiac monitor provides continuous rhythm surveillance and is the most sensitive method for detecting paroxysmal AF. The negative findings over this extended period make occult AF highly unlikely. 1

• Guidelines recommend anticoagulation when AF is detected, even if brief (as short as 6 minutes in some studies), but your monitor never captured any AF episodes. 5

Important Caveats and Next Steps

Before Discontinuing Apixaban

• Confirm with your cardiologist or electrophysiologist that:
  • The implantable monitor data has been thoroughly reviewed and shows no AF episodes
  • There is no other indication for anticoagulation (such as mechanical heart valve, left ventricular thrombus, or hypercoagulable state)
  • Your CHA₂DS₂-VASc score and stroke risk factors are documented 1

Alternative Scenarios to Consider

• If you have subclinical atrial fibrillation (device-detected episodes 6 minutes to 24 hours) with a history of stroke or TIA, recent evidence suggests apixaban may provide benefit. However, you stated your monitor never caught AF, so this does not apply. 5

• If you had embolic stroke of undetermined source (ESUS), apixaban was not superior to aspirin in preventing recurrent ischemic lesions, so anticoagulation would not be indicated even in that scenario. 6

Post-Discontinuation Monitoring

• Continue periodic follow-up with cardiology to monitor for any new symptoms suggestive of arrhythmia (palpitations, unexplained dyspnea, presyncope). 1

• If your implantable monitor is still in place, ensure it remains active and that you have a plan for responding to any future alerts. 1

• Consider annual ECG screening, though the yield will be low given your extensive negative monitoring history. 1

Common Pitfall to Avoid

• Do not confuse SVT with atrial fibrillation. Some clinicians may have initially suspected AF and started anticoagulation empirically, but your definitive testing ruled this out. SVT does not require anticoagulation. 1

• Avoid continuing anticoagulation "just to be safe" without documented indication. The bleeding risk is real (2.26% per year in high-risk patients), and the benefit only exists when AF is present. 4, 5