In a patient with atrial fibrillation on apixaban (Eliquis) who is scheduled for atrial fibrillation ablation and permanent pacemaker implantation, should the apixaban be held?

Should Eliquis Be Held for AF Ablation and PPM Placement?

For AF ablation, perform the procedure with uninterrupted apixaban (Eliquis); for permanent pacemaker implantation, hold apixaban for 24-48 hours before the procedure depending on bleeding risk.

AF Ablation: Uninterrupted Anticoagulation

Catheter ablation for atrial fibrillation should be performed with uninterrupted oral anticoagulation 1. This is now the standard of care based on multiple randomized trials demonstrating superior safety and efficacy of uninterrupted DOACs compared to interrupted anticoagulation with bridging 1.

Evidence Supporting Uninterrupted Apixaban for Ablation:

• The AXAFA-AFNET 5 trial (674 patients) demonstrated that continuous apixaban was non-inferior to vitamin K antagonists for the composite outcome of death, stroke, or bleeding during AF ablation 2
• The AEIOU trial (300 patients) showed both uninterrupted and minimally interrupted (holding 1 dose) apixaban had similar low rates of major bleeding (<2%) and no thromboembolic events 3
• Multiple meta-analyses confirm apixaban has equivalent safety and efficacy to warfarin for periprocedural anticoagulation during AF ablation 4, 5

Practical Approach for AF Ablation:

• Continue apixaban through the procedure - take the morning dose on the day of ablation
• Alternative acceptable approach: hold 1-2 doses before ablation with early reinitiation 6-12 hours post-ablation 1
• No bridging anticoagulation is needed or recommended 1
• Resume apixaban 6-8 hours after the procedure once hemostasis is established 1

Permanent Pacemaker Implantation: Hold Apixaban

For permanent pacemaker placement, the approach differs from ablation because this is a surgical procedure with pocket creation and higher bleeding risk.

Timing of Interruption:

According to the FDA label for Eliquis and current guidelines 6:

For procedures with moderate-to-high bleeding risk (which includes PPM implantation):

• Hold apixaban for at least 48 hours before the procedure if creatinine clearance ≥30 mL/min
• Extend to 72 hours if creatinine clearance 15-29 mL/min 7

For procedures with low bleeding risk:

• Hold for 24 hours if creatinine clearance ≥30 mL/min
• Extend to 36 hours if creatinine clearance 15-29 mL/min 8

Key Considerations for PPM:

• No bridging anticoagulation is recommended - DOACs have rapid onset/offset, making bridging unnecessary and potentially harmful 1, 9
• The PAUSE study (3,007 patients) demonstrated that standardized DOAC interruption without bridging resulted in low rates of both major bleeding (1.35% for apixaban) and stroke (0.16% for apixaban) 1
• Bridging with heparin increases bleeding risk (2.7% vs 0.5%) without reducing thromboembolic events 1

Resumption After PPM:

• Restart apixaban 48-72 hours after the procedure once adequate hemostasis is established 7
• For high bleeding risk procedures, wait toward the longer end of this range (72 hours) 6
• Resume at the usual dose - no loading dose needed due to rapid onset of action

Critical Pitfalls to Avoid:

1. Do not bridge with heparin - this significantly increases bleeding risk without benefit for DOAC interruption 1, 9
2. Adjust timing based on renal function - patients with impaired renal function require longer interruption periods 7
3. Do not confuse ablation with device implantation - ablation is performed with uninterrupted anticoagulation, while PPM requires interruption
4. Account for drug interactions - if patient is on combined P-gp and strong CYP3A4 inhibitors (ketoconazole, ritonavir), apixaban clearance is prolonged 6

Algorithm Summary:

AF Ablation:

• Continue apixaban → Perform ablation → Resume 6-8 hours post-procedure

PPM Implantation:

• Hold apixaban 48 hours pre-procedure (normal renal function) → Perform PPM → Resume 48-72 hours post-procedure when hemostasis established
• No bridging in either scenario