What are the recommendations for managing factor X (factor 10) inhibitors, such as rivaroxaban (Xarelto) and apixaban (Eliquis), in patients undergoing a Transesophageal Echocardiogram (TEE)?

Management of Factor Xa Inhibitors for Patients Undergoing TEE

For patients on factor Xa inhibitors (rivaroxaban, apixaban) undergoing transesophageal echocardiogram (TEE), the recommended approach is to discontinue the anticoagulant 24 hours before the procedure and restart the next day after the procedure. 1

Risk Assessment and Discontinuation Protocol

TEE is generally considered a procedure with low bleeding risk, but it involves instrumentation of the esophagus which carries some risk of bleeding complications. The management approach should follow these principles:

1. Timing of Discontinuation:

   • Last dose of factor Xa inhibitor should be given 24 hours before the scheduled TEE 1
   • No bridging therapy with heparin is required for this short interruption 2

2. Patient Risk Stratification:

   • High thrombotic risk patients: Those with recent VTE (<3 months), active cancer, or mechanical heart valves 2
   • Moderate risk: Patients with atrial fibrillation and CHA₂DS₂-VASc score ≥4
   • Low risk: Patients with atrial fibrillation and CHA₂DS₂-VASc score <4, or VTE >3 months ago

3. Resumption Protocol:

   • Restart the factor Xa inhibitor the day after the procedure (approximately 24 hours post-procedure) 1
   • For patients at high risk of thromboembolism, consider restarting as soon as hemostasis is assured

Evidence-Based Considerations

The PERIXa study demonstrated that following a standardized protocol of discontinuing factor Xa inhibitors 24 hours before low bleeding risk procedures (including endoscopic procedures) and restarting the next day resulted in very low rates of major bleeding (0.1%) and no thromboembolic events 1. This provides strong evidence supporting this approach for TEE procedures.

For patients with atrial fibrillation undergoing elective cardioversion with TEE guidance, therapeutic anticoagulation with factor Xa inhibitors is recommended for at least 3 weeks before cardioversion 2. In these cases, the TEE is performed while on anticoagulation, and the brief interruption described above would not apply.

Important Caveats

• Do not discontinue factor Xa inhibitors for longer than necessary, as this increases thrombotic risk
• Standard coagulation tests (PT, PTT, INR) are not reliable indicators of anticoagulant effect for factor Xa inhibitors 3
• For emergency TEE in patients on factor Xa inhibitors with active bleeding, prothrombin complex concentrate (PCC) may be considered for reversal 4
• No bridging with heparin is needed for this short interruption in most patients 2

Special Populations

• Cancer patients: May have higher thrombotic risk; consider minimizing time off anticoagulation 5
• Renal impairment: No dose adjustment needed for the interruption protocol, but consider the patient's renal function when restarting the medication
• Elderly patients: Follow the same protocol, but monitor more closely for bleeding complications

This approach balances the risk of periprocedural bleeding against the risk of thromboembolism, with evidence showing excellent safety outcomes when following the 24-hour discontinuation protocol for low bleeding risk procedures like TEE.