What are the recommendations for managing apixaban (Eloquis) in patients undergoing cardiac catheterization?

Management of Apixaban (Eliquis) for Cardiac Catheterization

For patients on apixaban (Eliquis) undergoing cardiac catheterization, the medication should be discontinued 48 hours prior to the procedure for most patients and resumed when adequate hemostasis has been established, typically 6-24 hours after the procedure. 1

Interruption Protocol for Apixaban Before Cardiac Catheterization

Standard Risk Patients

• Discontinue apixaban 48 hours before the procedure for elective cardiac catheterization with moderate to high bleeding risk 1
• Discontinue apixaban 24 hours before the procedure for procedures with low bleeding risk 1

High-Risk Patients

For patients with high bleeding risk (such as those with renal impairment):

• Extend discontinuation period to 3 days before the procedure for patients with normal renal function 2
• For patients with impaired renal function, timing should be adjusted according to creatinine clearance:
  • CrCl >50 mL/min: 3 days before procedure
  • CrCl 30-50 mL/min: 4 days before procedure 2

Very High-Risk Procedures

For procedures with very high bleeding risk (e.g., neuraxial anesthesia):

• Longer interruption times are required (up to 5 days) 2

Bridging Anticoagulation

• No bridging with heparin is generally required before the procedure 2
• Exception: Consider bridging only for patients at very high thrombotic risk 2

Resumption Protocol After Cardiac Catheterization

Timing of Resumption

• Resume apixaban when adequate hemostasis is achieved, typically:
  • 6 hours after procedure for low bleeding risk procedures
  • 24-72 hours after procedure for higher bleeding risk procedures 2, 1

Dosing for Resumption

• Resume the same dose regimen the patient was on prior to the procedure 1
• For twice-daily regimen: Resume the evening of the procedure if hemostasis is adequate
• For once-daily regimen with morning intake: Resume the next morning
• For once-daily regimen with evening intake: Resume the evening of the procedure if hemostasis is adequate 2

Special Considerations

Uninterrupted Anticoagulation for AF Ablation

• For patients undergoing AF catheter ablation specifically, uninterrupted oral anticoagulation is recommended to prevent peri-procedural ischemic stroke and thromboembolism 2
• This differs from the management for standard cardiac catheterization

Post-Procedure Monitoring

• Monitor for signs of bleeding at the access site
• Monitor renal function post-procedure as changes may affect apixaban dosing 2
• If the procedure affects renal function, apixaban dosing may need adjustment 2

Potential Complications

• Delayed and severe access site hemorrhagic complications can occur with anticoagulants after cardiac catheterization 3
• Neurological complications can occur if spinal/epidural anesthesia is used while anticoagulated 1

Important Caveats

• Never perform spinal or epidural anesthesia in patients with insufficient apixaban discontinuation time 2
• If traumatic puncture occurs during the procedure, delay resumption of apixaban for 48 hours 1
• For patients with mechanical heart valves, apixaban is not recommended 1
• The half-life of apixaban is approximately 12 hours, and its anticoagulant effect persists for about 24 hours after the last dose 4

By following these guidelines, clinicians can minimize both thrombotic and bleeding risks in patients on apixaban undergoing cardiac catheterization.