When can I resume taking Eliquis (apixaban) after a Coronary Artery Bypass Graft (CABG) procedure?

Resuming Eliquis After CABG

Eliquis (apixaban) should be restarted as soon as adequate hemostasis has been established after CABG surgery, typically within 24 hours post-procedure if there are no bleeding concerns. 1, 2

Timing of Apixaban Resumption After CABG

The timing for resuming anticoagulation after CABG follows a structured approach:

1. Immediate post-operative period (first 24 hours):

   • Assess for hemostasis and bleeding risk
   • Monitor for post-CABG thrombocytopenia (platelet count < 50,000 10^9/L), which may delay anticoagulant resumption 2

2. When hemostasis is adequate:

   • Resume apixaban within 24 hours after surgery if no bleeding concerns exist 2, 1
   • No bridging anticoagulation is required when restarting apixaban 1

3. Special considerations:

   • If post-operative bleeding risk remains high, delay resumption until risk decreases
   • For patients with mechanical heart valves or high thrombotic risk, earlier resumption may be considered

Evidence-Based Rationale

The FDA label for apixaban (Eliquis) states that it "should be restarted after surgical or other procedures as soon as adequate hemostasis has been established" 1. This aligns with the 2022 American College of Chest Physicians (ACCP) guidelines, which suggest resuming antiplatelet drugs within 24 hours after CABG surgery rather than delaying beyond 24 hours 2.

While the guidelines don't specifically address direct oral anticoagulants (DOACs) like apixaban after CABG, the recommendation for early resumption of antithrombotic therapy applies to the general principle of balancing bleeding and thrombotic risks.

Bleeding Risk Considerations

Bleeding is a significant concern after CABG, particularly:

• Pericardial tamponade (potentially life-threatening)
• Surgical site bleeding
• Need for reoperation due to bleeding

The risk of major bleeding complications decreases significantly after the first 24-48 hours post-CABG, making this the optimal window for resuming anticoagulation once hemostasis is confirmed 2.

Thrombotic Risk Considerations

Early post-CABG period carries thrombotic risks that anticoagulation helps mitigate:

• Graft thrombosis
• Atrial fibrillation (occurs in approximately one-third of post-CABG patients) 2
• Venous thromboembolism

Common Pitfalls to Avoid

1. Premature resumption: Restarting apixaban before adequate hemostasis increases bleeding risk
2. Excessive delay: Postponing anticoagulation beyond 24-48 hours when hemostasis is adequate may increase thrombotic risk
3. Failure to monitor: Not checking for post-CABG thrombocytopenia before resuming anticoagulation
4. Inappropriate bridging: Using parenteral anticoagulants when transitioning back to apixaban is generally unnecessary 1

Algorithm for Resuming Apixaban After CABG

1. Day of surgery and POD #1: Hold apixaban, monitor for bleeding
2. POD #1-2: Assess hemostasis:
   • If adequate hemostasis achieved: Resume apixaban at previous dose
   • If concerns about bleeding: Delay resumption and reassess every 12-24 hours
3. By POD #2-3: Most patients should be restarted on apixaban if no bleeding complications
4. Special situations:
   • For patients with high thrombotic risk: Consider resuming as early as possible once hemostasis is achieved
   • For patients with post-CABG thrombocytopenia: Delay until platelet count recovers 2

By following this approach, you can optimize the balance between preventing thrombotic complications while minimizing bleeding risk after CABG surgery.