When to hold Eliquis (apixaban) in patients with paroxysmal atrial fibrillation?

When to Hold Apixaban (Eliquis) in Patients with Paroxysmal Atrial Fibrillation

For patients with paroxysmal atrial fibrillation on apixaban (Eliquis), hold the medication for at least 48 hours before elective surgery or invasive procedures with moderate to high bleeding risk, and at least 24 hours before procedures with low bleeding risk.

Timing of Apixaban Interruption

The timing of apixaban interruption depends on the bleeding risk of the procedure:

High to Moderate Bleeding Risk Procedures

• Hold apixaban for at least 48 hours prior to elective surgery or invasive procedures with moderate to high risk of unacceptable or clinically significant bleeding 1
• Examples include:
  • Major cardiac, vascular, or orthopedic surgery
  • Neurosurgery
  • Major abdominal or pelvic surgery
  • Spinal or epidural procedures
  • Procedures requiring complete hemostasis

Low Bleeding Risk Procedures

• Hold apixaban for at least 24 hours prior to elective surgery or invasive procedures with low bleeding risk 1
• Examples include:
  • Dental extractions
  • Skin biopsies
  • Cataract surgery
  • Endoscopy without biopsy

Special Considerations

Cardioversion for Paroxysmal AF

• For electrical or pharmacological cardioversion of AF, apixaban can be continued without interruption
• The 2018 CHEST guidelines strongly recommend therapeutic anticoagulation for at least 3 weeks before cardioversion for AF lasting >48 hours or of unknown duration 2
• After successful cardioversion, continue apixaban for at least 4 weeks regardless of baseline stroke risk 2

Catheter Ablation Procedures

• For AF ablation procedures, uninterrupted apixaban is preferred over interrupted therapy
• Evidence shows that continuous apixaban during ablation is safe and effective with respect to bleeding and stroke risk 3
• Uninterrupted apixaban therapy may reduce the periprocedural risk of subclinical hypercoagulable states compared to interrupted therapy 4

Renal Function Considerations

• For patients with impaired renal function, the standard interruption times should still be followed
• No specific adjustment to the interruption timing is needed based on renal function alone, though these patients may be at higher bleeding risk

Resuming Apixaban After Procedures

• Restart apixaban as soon as adequate hemostasis has been established 1
• For most minor procedures, apixaban can typically be resumed 24 hours post-procedure
• For major procedures, consider waiting 48-72 hours before resuming full-dose anticoagulation
• Bridging anticoagulation during the 24 to 48 hours after stopping apixaban and prior to the intervention is not generally required 1

Important Caveats

• Never discontinue apixaban without medical supervision due to the increased risk of stroke during interruption
• The decision to interrupt anticoagulation must always balance thromboembolic risk against bleeding risk
• For emergency procedures, consider the use of andexanet alfa, which can be useful for the reversal of apixaban in the event of life-threatening or uncontrolled bleeding 2
• Patients with mechanical heart valves require different management and bridging therapy with unfractionated heparin or low-molecular-weight heparin 2

Remember that the risk of stroke is higher with non-paroxysmal AF compared to paroxysmal AF, but the pattern of AF should not affect the decision regarding long-term oral anticoagulation 2. Apixaban is effective in reducing stroke risk regardless of AF type (paroxysmal vs. persistent/permanent) 5.