Is bridging from Eliquis (apixaban) to heparin necessary for a patient with atrial fibrillation (AFIB)?

From the Guidelines

Bridging from Eliquis to heparin is typically not necessary for most patients with atrial fibrillation. When transitioning between anticoagulants, Eliquis can usually be discontinued and heparin started at the time the next dose of Eliquis would have been due, without an overlap period. This is because apixaban has a relatively short half-life of approximately 12 hours in most patients with normal renal function, as supported by the 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. For patients undergoing procedures, Eliquis is generally stopped 24-48 hours before high-bleeding-risk procedures and 12-24 hours before low-bleeding-risk procedures, with heparin started afterward if necessary.

The decision to bridge should be individualized based on the patient's specific thromboembolic risk factors, bleeding risk, and the nature of any planned procedures. Patients with mechanical heart valves, recent stroke/TIA, or very high CHADS2-VASc scores may warrant consideration of bridging in certain circumstances, as noted in the 2019 AHA/ACC/HRS focused update 1. However, the BRIDGE study found that absence of bridging was noninferior to bridging with low-molecular-weight heparin for prevention of arterial thromboembolism and decreased the risk of bleeding 1.

When restarting Eliquis after a procedure, it can typically be resumed once adequate hemostasis is achieved, usually within 24-48 hours for most procedures, without the need for heparin bridging during reinitiation. The European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation also supports this approach, recommending that NOAC intake can be resumed 3–5 h after sheath removal if adequate haemostasis is established and pericardial effusion has been ruled out 1.

Key considerations for bridging decisions include:

• Patient's thromboembolic risk factors
• Bleeding risk
• Nature of planned procedures
• Renal function
• CHADS2-VASc score
• Operator experience
• Routine practice of heparin administration prior to trans-septal puncture. In general, bridging anticoagulation may be appropriate only in patients with a very high thromboembolic risk, as stated in the 2019 AHA/ACC/HRS focused update 1.

From the FDA Drug Label

Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled. Bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required

No, bridging from Eliquis (apixaban) to heparin is not generally required for a patient with atrial fibrillation (AFIB) 2.

From the Research

Bridging from Eliquis to Heparin for Patients with AFIB

• The decision to bridge from Eliquis (apixaban) to heparin for patients with atrial fibrillation (AFIB) depends on various factors, including the patient's individual risk of thromboembolism and bleeding.
• Studies have shown that bridging anticoagulation with low-molecular-weight heparin may not be necessary for patients with AFIB who require an interruption in warfarin treatment for an elective operation or other elective invasive procedure 3, 4.
• The BRIDGE trial found that forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding 3.
• Another study found that apixaban has similar safety and effectiveness to warfarin for the prevention of cerebral thromboembolism during the periprocedural period of AF ablation, and that bridging with heparin may not be necessary in this setting 5.
• The AUGUSTUS trial found that apixaban was associated with lower rates of major or clinically relevant nonmajor bleeding and death or hospitalization than vitamin K antagonists (VKA) in patients with AF and recent acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI), regardless of prior stroke or transient ischemic attack (TIA) 6.

Key Considerations

• The risk of thromboembolism and bleeding should be carefully assessed on an individual basis.
• The use of bridging anticoagulation with heparin should be considered on a case-by-case basis, taking into account the patient's specific clinical circumstances.
• The choice of anticoagulant and the decision to bridge or not should be made in consultation with a healthcare professional, taking into account the latest clinical guidelines and evidence-based recommendations 7.