Do you hold Eliquis (apixaban) for Transesophageal Echocardiography (TEE)?

From the Guidelines

Eliquis (apixaban) does not need to be held before a Transesophageal Echocardiography (TEE) in most cases, as the current evidence suggests that the risk of bleeding is low and the benefits of continuing anticoagulation outweigh the risks 1. When considering the management of anticoagulation in patients undergoing TEE, it is essential to weigh the risks of bleeding against the risks of thromboembolism. The evidence from recent studies, such as the Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) RCT, suggests that the use of non-vitamin K antagonist oral anticoagulants (NOACs) like apixaban is safe and effective in the setting of TEE-guided cardioversion 1. Some key points to consider when managing anticoagulation in patients undergoing TEE include:

• The risk of bleeding associated with TEE is low, and the benefits of continuing anticoagulation outweigh the risks in most cases 1.
• The use of NOACs like apixaban has been shown to be safe and effective in the setting of TEE-guided cardioversion, with a low risk of thromboembolism and bleeding 1.
• The decision to hold or continue anticoagulation should be individualized based on the patient's specific risk factors for thromboembolism and bleeding, and should be determined in consultation with the cardiologist performing the procedure 1. In general, the current evidence suggests that Eliquis (apixaban) can be continued in most patients undergoing TEE, without the need for interruption or bridging therapy 1. However, the exact management strategy should be determined on a case-by-case basis, taking into account the individual patient's risk factors and clinical circumstances.

From the FDA Drug Label

When neuraxial anesthesia (spinal/epidural anesthesia) or spinal/epidural puncture is employed, patients treated with antithrombotic agents for prevention of thromboembolic complications are at risk of developing an epidural or spinal hematoma which can result in long-term or permanent paralysis The risk of these events may be increased by the postoperative use of indwelling epidural catheters or the concomitant use of medicinal products affecting hemostasis. Indwelling epidural or intrathecal catheters should not be removed earlier than 24 hours after the last administration of apixaban tablets The next dose of apixaban tablets should not be administered earlier than 5 hours after the removal of the catheter.

Eliquis (apixaban) should be held for Transesophageal Echocardiography (TEE) as it is a form of invasive procedure that carries a risk of bleeding, and the label recommends caution with neuraxial procedures.

• The label does not provide specific guidance on TEE, but it does discuss the risks associated with neuraxial anesthesia and puncture.
• Given the potential risks, it is reasonable to exercise caution and hold Eliquis (apixaban) for TEE, similar to other invasive procedures with a risk of bleeding 2.

From the Research

Anticoagulation Management for Transesophageal Echocardiography (TEE)

• The provided studies do not directly address the management of Eliquis (apixaban) for TEE, but they offer insights into anticoagulation strategies for patients undergoing cardioversion, which may involve TEE.
• A study from 2006 3 evaluated the safety of an expedited anticoagulation regimen in patients undergoing TEE-guided cardioversion, using intravenous unfractionated heparin and low-molecular-weight heparin, and found it to be safe.
• Another study from 2001 4 discussed the role of TEE-guided cardioversion and the use of anticoagulation therapy to decrease the risk of thromboembolism, suggesting that a TEE-guided strategy may lower stroke and bleeding events.
• A 2015 study 5 investigated the safety of fondaparinux in patients undergoing TEE-guided electric cardioversion of atrial fibrillation and found it to be well-tolerated with similar efficacy to unfractionated heparin plus vitamin K antagonist.
• A 2019 review 6 on transesophageal echocardiography highlighted its indications, including the assessment of cardiac source of embolism and suspected endocarditis, but did not specifically address anticoagulation management for TEE.
• A 2005 prospective study 7 assessed the effectiveness and safety of brief anticoagulation therapy with enoxaparin in atrial fibrillation patients undergoing cardioversion, using pre- and post-cardioversion TEE evaluations, and found that a brief anticoagulation therapy using low-molecular-weight heparins appears to be safe and feasible.

Considerations for Eliquis (Apixaban) Management

• While the studies do not directly address Eliquis management for TEE, they suggest that anticoagulation strategies can be tailored based on individual patient risk factors and the results of TEE evaluations.
• The decision to hold or continue Eliquis for TEE should be made on a case-by-case basis, considering the patient's underlying condition, the reason for the TEE, and the potential risks and benefits of anticoagulation therapy, as informed by studies such as those cited 3, 4, 5, 7.