Does a 74-year-old patient with a history of atrial fibrillation (A-fib) and stroke, taking aspirin and Eliquis (apixaban) daily, need to discontinue Eliquis and bridge with Lovenox (enoxaparin) for hernia repair surgery?

From the Guidelines

A 74-year-old patient with atrial fibrillation and prior stroke taking aspirin and Eliquis (apixaban) should temporarily discontinue Eliquis before hernia repair surgery, but bridging with Lovenox (enoxaparin) is typically not necessary. Eliquis should be stopped 48 hours before the procedure if the bleeding risk is standard, or 72 hours if bleeding risk is high, as suggested by the study 1. The patient's renal function should also be considered when determining the timing of Eliquis discontinuation, with a longer discontinuation period recommended for patients with moderate renal impairment (CrCl 30-50 mL/min) 1. The patient should also discontinue aspirin 7 days before surgery unless specifically instructed otherwise by their cardiologist, as recommended by the French working group on perioperative haemostasis (GIHP) and the French study group on thrombosis and haemostasis (GFHT) 1. After surgery, Eliquis can usually be resumed 24-48 hours postoperatively when adequate hemostasis is achieved. The decision to bridge with Lovenox is generally not recommended for patients on direct oral anticoagulants like Eliquis, as it increases bleeding risk without providing significant thrombotic protection, as stated in the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. However, this recommendation may vary based on the patient's specific CHADS2-VASc score (which assesses stroke risk) and individual bleeding risk. The surgeon and cardiologist should collaborate on the perioperative anticoagulation plan, considering both the risk of thromboembolism from the patient's A-fib and stroke history against the bleeding risk associated with hernia surgery. Some key points to consider in the perioperative management of this patient include:

• The risk of stroke and thromboembolism associated with atrial fibrillation
• The risk of bleeding associated with hernia surgery
• The patient's renal function and its impact on Eliquis discontinuation
• The role of aspirin in the patient's antithrombotic regimen
• The potential need for bridging anticoagulation with Lovenox (enoxaparin) It is essential to weigh these factors carefully and make a decision based on the most recent and highest-quality evidence, such as the studies by 1, 1, and 1.

From the FDA Drug Label

Apixaban tablets may need to be stopped, if possible, prior to surgery or a medical or dental procedure Ask the doctor who prescribed apixaban tablets for you when you should stop taking it. Your doctor will tell you when you may start taking apixaban tablets again after your surgery or procedure. If you have to stop taking apixaban tablets, your doctor may prescribe another medicine to help prevent a blood clot from forming

The patient may need to discontinue Eliquis prior to hernia repair surgery. The decision to discontinue Eliquis and bridge with Lovenox should be made by the doctor who prescribed Eliquis, as they will determine the best course of action to prevent blood clots during surgery 2.

From the Research

Patient Profile

• 74-year-old patient with a history of atrial fibrillation (A-fib) and stroke
• Currently taking aspirin and Eliquis (apixaban) daily
• Needs clearance for hernia repair surgery

Anticoagulation Management

• The patient is at high risk of stroke due to their history of A-fib and stroke 3, 4, 5
• Apixaban has been shown to be effective in reducing the risk of stroke or systemic embolism in patients with A-fib, including those with a history of stroke or transient ischaemic attack 4, 5
• The risk of major bleeding is increased with apixaban compared to aspirin, but the absolute risk difference is relatively small 4, 5

Perioperative Anticoagulation Management

• There is no direct evidence from the provided studies on the specific management of anticoagulation in patients with A-fib undergoing hernia repair surgery
• However, the studies suggest that apixaban is effective and safe for stroke prevention in patients with A-fib, including those with a history of stroke or transient ischaemic attack 4, 5
• The decision to discontinue Eliquis and bridge with Lovenox (enoxaparin) should be made on a case-by-case basis, taking into account the patient's individual risk factors and the surgical procedure 6, 7

Key Considerations

• The patient's history of A-fib and stroke increases their risk of thromboembolic events
• Apixaban has been shown to be effective in reducing this risk, but the risk of major bleeding is increased
• The decision to discontinue Eliquis and bridge with Lovenox should be made in consultation with the patient's healthcare team, taking into account their individual risk factors and the surgical procedure.