What are the perioperative management recommendations for an 87-year-old female with atrial fibrillation, hypertension, heart failure, and severe tricuspid regurgitation undergoing robotic-assisted right anterior hip replacement, taking Eliquis (apixaban) and Farxiga (dapagliflozin)?

From the Guidelines

Perioperative management for this 87-year-old female with multiple cardiac comorbidities undergoing robotic-assisted right anterior hip replacement should prioritize anticoagulation management, with apixaban (Eliquis) discontinued 48-72 hours before surgery and dapagliflozin (Farxiga) held 24 hours before surgery. The decision to hold these medications is based on the latest guidelines and studies, including the 2022 American College of Chest Physicians clinical practice guideline 1, which recommends interrupting direct oral anticoagulants (DOACs) such as apixaban for 1 to 2 days before elective surgery. Additionally, the 2025 study on therapeutic novelties in acute heart failure and practical perspectives 1 suggests that sodium-glucose co-transporter-2 inhibitors like dapagliflozin should be interrupted for at least 3 days before surgery to prevent perioperative euglycemic ketoacidosis.

Key Considerations

• Apixaban should be discontinued 48-72 hours before surgery, depending on renal function and bleeding risk, with potential bridging using low molecular weight heparin if the CHA₂DS₂-VASc score is high 1.
• Dapagliflozin should be held 24 hours before surgery to prevent perioperative euglycemic ketoacidosis, and restarted only after stable oral intake is established and renal function is stable 1.
• Preoperative cardiac evaluation, including echocardiography, is essential to assess heart failure status and tricuspid regurgitation severity.
• Intraoperative management should include careful fluid administration, continuous cardiac monitoring, and maintenance of adequate blood pressure to prevent heart failure exacerbation.
• Postoperatively, apixaban should be resumed 24-48 hours after surgery when hemostasis is achieved, with consideration for initial prophylactic dosing before returning to therapeutic levels.

Medication Management

• Apixaban (Eliquis): discontinue 48-72 hours before surgery, with potential bridging using low molecular weight heparin if CHA₂DS₂-VASc score is high 1.
• Dapagliflozin (Farxiga): hold 24 hours before surgery, and restart only after stable oral intake is established and renal function is stable 1.
• Metoprolol XL: continue perioperatively, as beta-blockers are recommended for patients with heart failure and reduced ejection fraction 1.
• Entresto: continue perioperatively, as angiotensin receptor neprilysin inhibitors are recommended for patients with heart failure and reduced ejection fraction 1.

Monitoring and Follow-up

• Close monitoring for signs of heart failure decompensation, arrhythmias, and volume status is crucial throughout the perioperative period.
• Adequate pain control with multimodal analgesia will help prevent hemodynamic fluctuations that could worsen cardiac function.
• Early mobilization should be encouraged to reduce thromboembolic risk while balancing the need for cardiac stability.

From the FDA Drug Label

When leaving the hospital following hip or knee replacement, be sure that you will have apixaban tablets available to avoid missing any doses. Tell all of your doctors and dentists that you are taking apixaban tablets . They should talk to the doctor who prescribed apixaban tablets for you, before you have any surgery, medical or dental procedure Do not stop taking it without first talking with your doctor. If you are taking apixaban tablets for atrial fibrillation, stopping apixaban tablets may increase your risk of having a stroke.

Perioperative Management Recommendations:

• The patient should not stop taking Eliquis (apixaban) without first talking to their doctor, as stopping the medication may increase the risk of having a stroke.
• The doctor should be informed about the patient's use of Eliquis (apixaban) before any surgery, medical, or dental procedure.
• It is recommended to have Eliquis (apixaban) available to avoid missing any doses after hospital discharge following hip or knee replacement surgery.
• Regarding Farxiga (dapagliflozin), there is no direct information in the provided drug label.
• However, for Eliquis (apixaban), the decision to hold or continue the medication should be made by the doctor, considering the patient's individual risk factors and medical history 2.

From the Research

Perioperative Management Recommendations

The patient's medical history, including atrial fibrillation, hypertension, heart failure, and severe tricuspid regurgitation, requires careful consideration in the perioperative management of robotic-assisted right anterior hip replacement.

• The patient is taking Eliquis (apixaban) and Farxiga (dapagliflozin), which may need to be held or managed carefully during the perioperative period.
• Studies have shown that tricuspid regurgitation is a predictor of adverse events in patients with heart failure 3, 4, 5, 6.
• The presence of severe tricuspid regurgitation in this patient may increase the risk of poor outcomes, including heart failure and mortality 4, 5, 6.
• The management of tricuspid regurgitation in congestive heart failure, including surgical management, has been reviewed, and strategies for analysis of outcomes have been discussed 7.
• However, there is no direct evidence to suggest that Eliquis and Farxiga should be held in this specific scenario.
• It is essential to consider the patient's individual risk factors, including the severity of tricuspid regurgitation, pulmonary hypertension, and left ventricular ejection fraction, when making decisions about perioperative management 3, 4, 5, 6.

Medication Management

• The decision to hold or continue Eliquis and Farxiga should be made in consultation with the patient's cardiologist and anesthesiologist, taking into account the patient's individual risk factors and the potential risks and benefits of continuing or discontinuing these medications.
• The patient's other medications, including atorvastatin, levothyroxine, metoprolol XL, and Entresto, should also be carefully managed during the perioperative period.

Additional Considerations

• Close monitoring of the patient's cardiac function, including echocardiography and electrocardiography, may be necessary during the perioperative period to assess for any changes in tricuspid regurgitation or other cardiac abnormalities 3, 4, 5, 6.
• The patient's pulmonary hypertension and right ventricular dysfunction should also be carefully managed during the perioperative period 4, 5, 6.