Do Not Hold Eliquis Before Cardioversion
You should continue Eliquis (apixaban) without interruption before cardioversion for atrial fibrillation. The most recent 2024 ESC guidelines explicitly recommend that direct oral anticoagulants like apixaban be continued as therapeutic oral anticoagulation for at least 3 weeks before scheduled cardioversion, and there is no recommendation to hold these medications 1.
Evidence-Based Approach to Anticoagulation Management
Continue Apixaban Through Cardioversion
Apixaban should be maintained at the patient's current dose (either 5 mg twice daily or 2.5 mg twice daily based on dose-reduction criteria) throughout the cardioversion procedure 1.
The 2024 ESC guidelines give a Class I, Level A recommendation that direct oral anticoagulants are preferred over vitamin K antagonists in eligible patients undergoing cardioversion for thromboembolic risk reduction 1.
The CHEST 2018 guidelines specifically state that "available data support the use of rivaroxaban, dabigatran, apixaban, and edoxaban in patients to be continued on these NOACs if scheduled for cardioversion" 1.
Pre-Cardioversion Anticoagulation Requirements
For scheduled cardioversion, ensure therapeutic anticoagulation for at least 3 weeks before the procedure:
Patients must demonstrate adherence to apixaban for at least 3 weeks prior to cardioversion 1.
The 2024 ESC guidelines recommend therapeutic oral anticoagulation for at least 3 weeks (adherence to DOACs or INR ≥2.0 for VKAs) before scheduled cardioversion to prevent procedure-related thromboembolism 1.
If 3 weeks of therapeutic anticoagulation has not been provided, transoesophageal echocardiography is recommended for exclusion of cardiac thrombus to enable early cardioversion 1.
Alternative TEE-Guided Approach
For patients requiring expedited cardioversion, a TEE-guided strategy allows earlier procedure:
NOACs like apixaban offer the advantage of quicker onset of action compared to warfarin, eliminating delays waiting for therapeutic INR 1.
In the TEE-guided approach, if no thrombus is visualized, cardioversion can proceed immediately while continuing apixaban 1.
The EMANATE trial specifically studied apixaban in anticoagulation-naïve patients undergoing cardioversion, demonstrating safety with either immediate cardioversion after imaging or a loading dose strategy 2, 3.
In EMANATE, 342 patients received a loading dose of 10 mg apixaban (or 5 mg if dose-reduced) to expedite cardioversion, with excellent safety outcomes 3.
Post-Cardioversion Management
Continue apixaban for at least 4 weeks after cardioversion in all patients:
The 2024 ESC guidelines recommend oral anticoagulation continue for at least 4 weeks in all patients after cardioversion, regardless of whether sinus rhythm is achieved 1.
Long-term anticoagulation should continue indefinitely in patients with thromboembolic risk factors, as the stroke risk persists regardless of rhythm status 1.
Atrial mechanical dysfunction can persist for several weeks following cardioversion even if sinus rhythm is restored on ECG, maintaining thromboembolism risk 1.
The highest risk of stroke and thromboembolism after cardioversion occurs in the first 72 hours, with most thromboembolic complications within 10 days 1.
Clinical Evidence Supporting Continuation
Safety and Efficacy Data
The ARISTOTLE post-hoc analysis of 743 cardioversions showed no strokes or systemic emboli occurred in the 30-day follow-up period in patients receiving apixaban, with major bleeding in only 0.3% 4.
A 2019 propensity-matched cohort study found similarly low incidence of thromboembolic events (1.1%) in both apixaban and warfarin groups, with bleeding safety profile favoring apixaban (1.1% vs 1.6%) 5.
The EMANATE trial demonstrated that apixaban had 0 strokes compared to 6 strokes in the heparin/VKA group among 1,500 patients undergoing cardioversion 3.
Meta-analysis data show NOACs have comparable efficacy to warfarin for cardioversion, with pooled relative risk of 0.82 for stroke/systemic embolism 1.
Critical Pitfalls to Avoid
Do not confuse cardioversion anticoagulation management with surgical procedures:
The FDA label for apixaban states that it should be discontinued 48 hours before elective surgery with moderate-to-high bleeding risk, but cardioversion is NOT a surgical procedure requiring anticoagulation interruption 6.
Cardioversion itself carries inherent stroke risk that is substantially reduced by anticoagulation—holding apixaban would increase thromboembolic risk 1.
Ensure patient adherence before cardioversion:
The need for strict adherence to apixaban therapy must be emphasized to patients, particularly in the post-cardioversion period 1.
Verify that patients have been taking apixaban consistently for at least 3 weeks before scheduled cardioversion 1.
Do not perform early cardioversion without appropriate anticoagulation:
- The 2024 ESC guidelines give a Class III recommendation against early cardioversion without appropriate anticoagulation or TEE if AF duration is longer than 24 hours 1.