A 58-year-old woman with paroxysmal AF and CHA₂DS₂-VASc score of 4 is anticoagulated on apixaban. She undergoes electrical cardioversion. How long should anticoagulation be continued after successful cardioversion?
- A At least 4 weeks post-cardioversion regardless of CHA₂DS₂-VASc score, with long-term anticoagulation thereafter given CHA₂DS₂-VASc ≥2 ✓
- B Anticoagulation can be stopped 48 hours post-cardioversion if sinus rhythm is maintained
- C Anticoagulation for 3 months post-cardioversion; then reassess need based on ECG Holter
- D Indefinite anticoagulation only if AF recurs within 30 days
Correct answer: A. At least 4 weeks post-cardioversion regardless of CHA₂DS₂-VASc score, with long-term anticoagulation thereafter given CHA₂DS₂-VASc ≥2
Explanation
ESC 2020 AF guidelines require at least 4 weeks of therapeutic anticoagulation after cardioversion regardless of CHA₂DS₂-VASc score, because myocardial stunning post-cardioversion temporarily impairs atrial mechanical function even when sinus rhythm is restored, increasing thromboembolic risk for 3–4 weeks. After 4 weeks, long-term anticoagulation is continued if CHA₂DS₂-VASc ≥2 in women (≥1 in men — excluding female sex). This patient scores 4, mandating long-term anticoagulation continuation.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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