What are the implications of Aortic valve replacement with Eliquis (Apixaban)?

From the Guidelines

Eliquis (apixaban) is not recommended for use in patients with mechanical aortic valve replacements, as warfarin is the standard anticoagulant due to its proven effectiveness in preventing valve thrombosis. For bioprosthetic valve replacements, Eliquis may be used after an initial period of warfarin therapy (usually 3-6 months), though this practice varies by surgeon preference and patient risk factors 1. The typical Eliquis dosage is 5 mg twice daily, with a reduced dose of 2.5 mg twice daily for patients who are over 80 years old, weigh less than 60 kg, or have significant kidney impairment.

Key Considerations

• The use of Eliquis after aortic valve replacement surgery should be individualized based on patient risk factors, such as atrial fibrillation, stroke risk, and bleeding risk 2.
• Warfarin is the preferred anticoagulant for mechanical valve replacements, with a target INR of 2.5 (range, 2.0–3.0) for the first 3 months after surgery, during which low-dose aspirin is also used 3.
• The selective use of VKA therapy might be considered after TAVI in patients at low bleeding risk on an individual basis, with warfarin being more effective than direct oral anticoagulants for reduction of death, myocardial infarction, and cerebrovascular events in patients undergoing TAVI with an indication for anticoagulation 3.

Anticoagulation Strategies

• For patients with bioprosthetic valve replacements, anticoagulation with warfarin to achieve an INR of 2.0 to 3.0 may be recommended for the first 3 to 6 months after implantation, followed by lifelong low-dose aspirin 4.
• The addition of low-dose aspirin to therapeutic warfarin may be recommended for patients with mechanical aortic valve replacements and risk factors for thromboembolism, such as atrial fibrillation or previous thromboembolic events 5.

Patient Monitoring

• Patients should be regularly monitored for signs of thromboembolism, bleeding, and other complications, with adjustments to anticoagulation therapy made as needed 1.
• Renal function should be regularly monitored, and dose adjustments made according to FDA dosing guidelines for Eliquis 1.

From the Research

Implications of Aortic Valve Replacement with Eliquis (Apixaban)

• The use of apixaban in patients with mechanical heart valves, including aortic valve replacement, has been explored in several studies 6, 7.
• A case report published in 2021 found that apixaban was effective and safe in a patient with atrial fibrillation and double mechanical heart valves, including an aortic valve replacement, for preventing prosthetic valve thrombosis and systemic embolism 6.
• However, a randomized trial published in 2023 found that apixaban did not demonstrate noninferiority to warfarin and was less effective than warfarin for the prevention of valve thrombosis or thromboembolism in patients with an On-X mechanical aortic valve 7.
• Another study published in 2022 compared outcomes of direct oral anticoagulants (DOACs), including apixaban, versus warfarin in patients with atrial fibrillation and valve replacement or repair, and found that DOACs were associated with similar mortality, lower bleeding, but higher stroke with bioprosthetic valve replacement compared with warfarin 8.
• A study published in 2019 evaluated the safety and efficacy of apixaban versus warfarin in patients with atrial fibrillation and prior bioprosthetic valve replacement or valve repair, and found that apixaban may be reasonable for patients with bioprosthetic valves or prior valve repair, although larger randomized trials are needed 9.
• A study published in 2023 found that anticoagulation with warfarin early after surgical aortic valve replacement using bioprosthetic valves was associated with lower all-cause mortality and decreased risk of thromboembolism, but increased risk of major bleeding events 10.

Key Findings

• Apixaban may be effective and safe in certain patients with mechanical heart valves, including aortic valve replacement, but its use is not universally recommended 6, 7.
• The choice of anticoagulant therapy after aortic valve replacement should be individualized based on patient characteristics and risk factors 8, 9, 10.
• Warfarin remains the only approved oral anticoagulant for long-term prophylaxis against valve thrombosis and thromboembolism in patients with mechanical heart valves, but apixaban and other DOACs may be considered in certain situations 6, 7.