When can apixaban (Eliquis) be safely discontinued after a patient has been in sinus rhythm for at least four weeks following atrial fibrillation, assuming a low CHA₂DS₂‑VASc score?

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Last updated: February 19, 2026 • View editorial policy

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When Can Eliquis Be Stopped After Being Out of AFib?

You cannot stop Eliquis (apixaban) simply because you are in sinus rhythm—the decision to discontinue anticoagulation must be based solely on your CHA₂DS₂-VASc stroke risk score, not on whether your heart rhythm appears normal. 1

The Critical Principle: Rhythm Does Not Determine Anticoagulation Need

Long-term anticoagulation decisions after cardioversion or spontaneous conversion to sinus rhythm should be made according to stroke risk stratification, not based on apparent success of rhythm restoration. 1, 2 This is a strong recommendation with moderate quality evidence from the CHEST guidelines. 1

Why Rhythm Status Doesn't Matter

The evidence supporting continued anticoagulation regardless of rhythm includes three key findings:

  • Approximately 50% of patients experience AF recurrence within 1 year after cardioversion, making long-term stroke risk significant even when initially appearing to be in sinus rhythm. 1, 2

  • The AFFIRM trial demonstrated that patients who stopped anticoagulation after apparently successful rhythm restoration had similar rates of thromboembolism compared to those on rate control strategies, proving that stopping anticoagulation based on rhythm is dangerous. 1, 2

  • Patients with paroxysmal AF are often asymptomatic during AF episodes, meaning you may be having recurrent AF without knowing it. 1

The 4-Week Rule for Post-Cardioversion Only

If you underwent cardioversion (electrical or pharmacologic), you must continue therapeutic anticoagulation for at least 4 weeks after successful cardioversion, regardless of your baseline stroke risk. 1 This is a strong recommendation from both CHEST and ESC guidelines. 1

After this mandatory 4-week period, decisions about continuing or stopping anticoagulation are based entirely on your CHA₂DS₂-VASc score, not on whether you remain in sinus rhythm. 1

How to Decide: The CHA₂DS₂-VASc Algorithm

Calculate Your Score

The CHA₂DS₂-VASc score includes:

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

Decision Based on Score

For males with CHA₂DS₂-VASc = 0 or females with CHA₂DS₂-VASc = 1 (only the sex point):

  • It is reasonable to stop anticoagulation (omit antithrombotic therapy). 1

For males with CHA₂DS₂-VASc = 1 or females with CHA₂DS₂-VASc = 2:

  • This is a gray zone where either continuing anticoagulation or stopping may be considered. 1
  • However, research shows these patients have an annual stroke rate of 2.55-2.75%, with age 65-74 carrying the highest risk at 3.34-3.50% per year. 3
  • Given this substantial stroke risk, oral anticoagulation should be strongly considered even with just one additional risk factor. 3

For males with CHA₂DS₂-VASc ≥2 or females with CHA₂DS₂-VASc ≥3:

  • Continue anticoagulation indefinitely—you cannot stop Eliquis. 1, 2
  • This is a Class I recommendation (strongest level). 1

Common Pitfalls to Avoid

Pitfall #1: Stopping Because "I Feel Fine"

Being asymptomatic does not mean you are not having AF episodes. 1 Silent AF still carries stroke risk. 1

Pitfall #2: Stopping After Successful Ablation

Even after catheter ablation, anticoagulation decisions are based on CHA₂DS₂-VASc score, not ablation success. 2 The European Heart Journal recommends continuing oral anticoagulation independent of rhythm outcome after ablation procedures. 2

Pitfall #3: Assuming Sinus Rhythm at 4 Weeks Means You're Cured

The 4-week post-cardioversion period is the minimum duration of anticoagulation required for safety after cardioversion itself. 1 Beyond 4 weeks, your underlying stroke risk factors (captured in CHA₂DS₂-VASc) determine whether you need lifelong anticoagulation. 1

Pitfall #4: Switching to Aspirin Instead

Aspirin is not recommended for stroke prevention in atrial fibrillation. 2 The risk of major bleeding with aspirin is similar to oral anticoagulation, especially in the elderly, but aspirin provides weak stroke protection. 1

Special Consideration: Truly Low-Risk Patients

The only patients who can safely stop Eliquis after being out of AFib are those who are truly low risk:

  • Males with CHA₂DS₂-VASc = 0 (no risk factors at all) 1
  • Females with CHA₂DS₂-VASc = 1 (only the female sex point, no other risk factors) 1

If you have even one additional stroke risk factor beyond sex, the annual stroke rate is 2.5-2.75%, which is too high to safely stop anticoagulation. 3

The Bottom Line

You can only stop Eliquis if you are truly low risk (male with CHA₂DS₂-VASc = 0 or female with CHA₂DS₂-VASc = 1). 1 Being in sinus rhythm for weeks, months, or even years does not change this recommendation. 1, 2 The decision is based on your underlying stroke risk factors, not your heart rhythm. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Anticoagulation Guidelines for Atrial Fibrillation

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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