Although not an official heir to the throne, after the death of Feodor Alexeevich, as eldest remaining son he should have succeeded. However, because of Ivan's ill health, the Boyars' Duma voted the 10-year-old Peter Alexeevich (the future Peter the Great) Czar on the suggestion of the Patriarch Ioakim. Following an insurrection of Ivan's relatives, the Miloslavskii boyars, led by Czarevna Sofia, opposed the election of Peter.

The Boyars' Duma gave way to these demands and declared Ivan First Czar, Peter Second Czar and Sofia Alexeevna Regent. Both Ivan and Peter were consecrated Czars on June 25, 1682.

Because of ill health, Ivan V played no role in political affairs of state. He married Praskovia Feodorovna Saltykova and had five children, including the future Empress Anna Ivanovna.

He died on January 29, 1696, and was buried in the Archangel Cathedral of the Kremlin.