Do you hold Eliquis (apixaban) before a Transesophageal Echocardiogram (TEE)?

From the Guidelines

Eliquis (apixaban) should typically be held before a Transesophageal Echocardiogram (TEE). The general recommendation is to discontinue apixaban for at least 24-48 hours prior to the procedure, depending on the patient's renal function and bleeding risk. For patients with normal renal function, holding apixaban for 24 hours is often sufficient, while those with impaired renal function may need to stop the medication 48 hours before the procedure. After the TEE, apixaban can usually be resumed 4-6 hours following the procedure if there were no complications and adequate hemostasis has been achieved. This temporary discontinuation is necessary because apixaban is an anticoagulant that inhibits factor Xa, which increases the risk of bleeding during invasive procedures like TEE where the esophageal probe might cause trauma to the esophageal mucosa. However, the decision to hold apixaban should always be individualized based on the patient's specific thrombotic risk versus bleeding risk, and in some high-risk patients for thromboembolism, bridging with shorter-acting anticoagulants might be considered. Always consult with the patient's cardiologist or the physician performing the TEE for specific instructions tailored to the individual patient.

Key Considerations

• The patient's renal function and bleeding risk should be taken into account when deciding how long to hold apixaban before the TEE procedure.
• The risk of thromboembolism and the need for anticoagulation should be assessed on a case-by-case basis, considering factors such as the duration of atrial fibrillation and the presence of other risk factors.
• The use of a TEE-guided approach for cardioversion has been shown to be effective in reducing the risk of thromboembolism, but the decision to use this approach should be made on an individual basis, taking into account the patient's specific risk factors and medical history 1.

Management of Anticoagulation

• Anticoagulation is recommended for 3 to 4 weeks before and after cardioversion for patients with atrial fibrillation of unknown duration or with atrial fibrillation for more than 48 hours.
• The choice of anticoagulant and the duration of therapy should be individualized based on the patient's risk factors and medical history.
• The use of bridging anticoagulation with shorter-acting anticoagulants may be considered in high-risk patients for thromboembolism 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 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.

Holding Eliquis (apixaban) before a Transesophageal Echocardiogram (TEE):

• The decision to hold Eliquis before a TEE depends on the bleeding risk associated with the procedure.
• If the TEE is considered an invasive procedure with a moderate or high risk of unacceptable or clinically significant bleeding, then Eliquis should be discontinued at least 48 hours prior to the procedure.
• If the TEE is considered an invasive procedure with a low risk of bleeding, then Eliquis should be discontinued at least 24 hours prior to the procedure 2.

From the Research

Holding Eliquis (Apixaban) Before TEE

• The decision to hold Eliquis (apixaban) before a Transesophageal Echocardiogram (TEE) depends on various factors, including the patient's individual risk of thromboembolism and the specific procedure being performed.
• According to a study published in 2022 3, apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure.
• However, another study published in 2016 4 found that performing AF ablation while on uninterrupted apixaban and rivaroxaban without TEE is feasible and safe, suggesting that holding Eliquis may not be necessary in all cases.
• The use of TEE to guide the management of atrial fibrillation may be considered a clinically effective alternative strategy to conventional therapy for patients in whom elective cardioversion is planned 5.
• It is essential to consider the patient's individual risk factors, such as CHA2DS2-VASc score, type of AF, and renal function, when deciding whether to hold Eliquis before TEE 6.

Considerations for Holding Eliquis

• The patient's risk of thromboembolism, as assessed by the CHA2DS2-VASc score, should be taken into account when deciding whether to hold Eliquis 6.
• The type of AF, non-paroxysmal or paroxysmal, may also influence the decision to hold Eliquis 6.
• Renal function, as measured by GFR, should also be considered when deciding whether to hold Eliquis 6.
• The specific procedure being performed, such as AF ablation or electrical cardioversion, may also impact the decision to hold Eliquis 4.