Should a 56-year-old male heavy smoker with normal left ventricular size, normal wall thickness, and low-normal global systolic function continue taking Eliquis (apixaban)?

Does This Patient Need to Continue Eliquis?

No, this patient should not continue Eliquis (apixaban) based on the cardiac workup provided, as there is no documented indication for anticoagulation. The studies show normal cardiac function with preserved ejection fraction (54-59%), normal sinus rhythm, and no evidence of atrial fibrillation, left ventricular thrombus, or recent venous thromboembolism 1.

Critical Missing Information

The question cannot be definitively answered without knowing why Eliquis was originally prescribed. The provided cardiac studies do not reveal:

• Atrial fibrillation history - The ECG shows sinus rhythm, but paroxysmal atrial fibrillation could exist 2
• Prior stroke or TIA - Would mandate continued anticoagulation 2
• History of venous thromboembolism (VTE) - DVT or pulmonary embolism within the past 3-12 months 2, 3
• Mechanical heart valve - Would require anticoagulation (though warfarin preferred over apixaban) 2, 1
• Left ventricular thrombus - Not visualized on current echocardiogram 2

Established Indications for Apixaban

Apixaban is FDA-approved for three specific conditions 1:

1. Atrial fibrillation - To reduce stroke risk (requires CHA₂DS₂-VASc score ≥2 for men, ≥3 for women) 3
2. VTE treatment - For acute DVT/PE and prevention of recurrence 2, 4
3. VTE prophylaxis - Following hip or knee replacement surgery 5

Analysis of Current Cardiac Status

The patient's cardiac workup shows NO current indication for anticoagulation:

• Normal left ventricular function - LVEF 54-59% by 3D imaging, which exceeds the <40% threshold that would warrant consideration of anticoagulation for thrombus prevention 2
• Normal wall motion - No regional wall motion abnormalities that would suggest recent myocardial infarction with thrombus risk 2
• Sinus rhythm - No documented atrial fibrillation on current ECG 2
• No valvular abnormalities - No hemodynamically significant valve disease requiring anticoagulation 2
• Inferior wall artifact - The poor radioisotope uptake is attributed to diaphragmatic artifact, not true ischemia 1

Risk Assessment for This Heavy Smoker

This 56-year-old heavy smoker has significant cardiovascular risk factors but no acute indication for anticoagulation 2:

• Heavy smoking increases coronary artery disease risk but does not independently warrant anticoagulation
• The intermediate-risk designation is due to inability to exercise, not cardiac pathology
• Aspirin 75-162 mg daily would be more appropriate for primary or secondary prevention of coronary events if no contraindications exist 2

When to Discontinue Apixaban

Based on established guidelines, apixaban should be discontinued when 3:

• VTE provoked by transient risk factor - Stop after 3 months if the risk factor (surgery, immobilization) has resolved 2, 3
• No ongoing indication - If atrial fibrillation has resolved permanently (rare) or was misdiagnosed 3
• Comfort care - When bleeding risks outweigh benefits and quality of life is prioritized 3

Apixaban should NOT be discontinued without physician consultation if:

• Paroxysmal atrial fibrillation exists (even if not captured on single ECG) 2
• Unprovoked VTE occurred within past 3-12 months 2, 3
• Patient has history of cardioembolic stroke 2

Recommended Action Plan

Immediate steps:

1. Review original indication - Obtain records documenting why apixaban was started 1
2. Assess for paroxysmal atrial fibrillation - Consider 24-48 hour Holter monitor or 30-day event monitor, as single ECG may miss paroxysmal episodes 2
3. Calculate CHA₂DS₂-VASc score if atrial fibrillation history exists - This patient would score points for age (0 points at 56) and vascular disease if present 3
4. Review bleeding risk - Heavy smoking may increase bleeding complications on anticoagulation 6

If no valid indication is found:

• Discontinue apixaban - Can be stopped abruptly without tapering or bridging 3, 1
• Consider aspirin - Start aspirin 75-162 mg daily for cardiovascular risk reduction given smoking history 2
• Aggressive risk factor modification - Smoking cessation, blood pressure control, lipid management 2

Critical Pitfalls to Avoid

• Do not assume sinus rhythm on one ECG excludes paroxysmal atrial fibrillation - Paroxysmal episodes require same anticoagulation as persistent atrial fibrillation 2
• Do not stop apixaban abruptly if atrial fibrillation exists - Stroke risk increases significantly within days of discontinuation 1
• Do not continue unnecessary anticoagulation - Bleeding risk (1-3% major bleeding annually) outweighs benefits when no indication exists 6
• Do not substitute aspirin for apixaban in atrial fibrillation - Aspirin is inferior for stroke prevention in atrial fibrillation 2