Should Eliquis Be Stopped After Conversion to Normal Sinus Rhythm?
No—do not stop Eliquis based solely on rhythm restoration; anticoagulation decisions must be driven exclusively by the patient's CHA₂DS₂-VASc stroke-risk score, not by whether sinus rhythm has been achieved or maintained. 1
Mandatory Post-Conversion Anticoagulation Period
- All patients must continue therapeutic anticoagulation for a minimum of 4 weeks after successful cardioversion to normal sinus rhythm, regardless of their baseline stroke risk. 2
- This 4-week requirement applies whether conversion was electrical, pharmacologic, or spontaneous. 2
- After this mandatory 4-week period, the decision to continue or discontinue anticoagulation is determined solely by stroke-risk stratification, not by rhythm status. 1
Long-Term Anticoagulation: CHA₂DS₂-VASc-Guided Algorithm
After the mandatory 4-week post-conversion period, use the following approach:
CHA₂DS₂-VASc Score = 0 (males) or 1 (females, sex point only)
- Stopping Eliquis is reasonable. 1, 3
- These are the only patients in whom discontinuation may be safely considered. 4
CHA₂DS₂-VASc Score = 1 (males) or 2 (females)
- Either continuing or stopping may be considered based on clinical judgment, but continuation is generally safer. 1
- This represents a gray zone where shared decision-making is appropriate, but err toward continuation given the consequences of stroke. 3
CHA₂DS₂-VASc Score ≥ 2 (males) or ≥ 3 (females)
- Continue Eliquis indefinitely; stopping is not advised. 1, 3, 4
- This is a strong recommendation regardless of how long sinus rhythm persists. 1
Why Rhythm Does Not Dictate Anticoagulation
- Approximately 50% of patients experience atrial fibrillation recurrence within one year after cardioversion, leaving them at continued stroke risk even when appearing to be in sinus rhythm. 1, 3
- Paroxysmal atrial fibrillation is frequently asymptomatic—patients may have recurrent episodes without awareness, preserving stroke risk. 1
- The AFFIRM trial demonstrated that patients who stopped anticoagulation after apparently successful rhythm restoration had thromboembolic rates comparable to those managed with rate-control strategies, proving the danger of stopping therapy based on rhythm alone. 1, 3
- Strokes often occur during periods of documented sinus rhythm in patients with a history of atrial fibrillation, indicating no temporal link between the arrhythmia and stroke. 3
Critical Pitfalls to Avoid
- "Feeling fine" or being asymptomatic does not exclude silent atrial fibrillation, which still confers stroke risk. 1
- Sinus rhythm persisting for weeks, months, or even years does not alter the need for anticoagulation—the decision is anchored to underlying stroke-risk factors, not rhythm. 1
- Never substitute aspirin for Eliquis; aspirin has comparable major-bleeding risk to oral anticoagulants while offering inferior stroke protection. 1, 4
- After catheter ablation, anticoagulation decisions remain based on CHA₂DS₂-VASc, not on procedural success. 1, 3
CHA₂DS₂-VASc Scoring Reference
Calculate the score using these components (1 point each unless noted):
- Congestive heart failure 1, 3
- Hypertension 1, 3
- Age ≥75 years (2 points) 1
- Diabetes 1
- Prior stroke/TIA/thromboembolism (2 points) 1
- Vascular disease 1, 3
- Age 65-74 years 1
- Female sex 1
Bottom Line
Only patients who are truly low-risk (male CHA₂DS₂-VASc = 0 or female CHA₂DS₂-VASc = 1) may safely discontinue Eliquis after the mandatory 4-week post-conversion period; all others should continue anticoagulation regardless of sinus rhythm duration. 1, 4