From the Guidelines
For patients undergoing Transcatheter Aortic Valve Replacement (TAVR), Apixaban (Eliquis) should be held for at least 24 to 48 hours prior to the procedure, depending on renal function, with the last dose taken no later than 2 days before the procedure, as suggested by the timing guidelines for non-vitamin K antagonist oral anticoagulants (NOACs) 1. When considering the management of anticoagulation in patients undergoing TAVR, it's crucial to balance the risk of bleeding against the risk of thromboembolic events. The guidelines for the management of oral anticoagulant therapy in patients undergoing invasive procedures suggest that for patients on Apixaban, the drug should be withheld for 24 hours (or 48 hours for patients with impaired renal function) before the procedure 1.
Key Considerations
- The biological half-life of Apixaban is approximately 12 hours, which allows for a relatively short period of drug discontinuation compared to vitamin K antagonists (VKAs) 1.
- The decision to hold Apixaban should take into account the patient's renal function, as this can affect the drug's half-life and the timing of the last dose before the procedure 1.
- Bridging anticoagulation with a parenteral agent is not typically recommended for patients on NOACs like Apixaban unless a longer period of interruption occurs 1.
Clinical Application
In clinical practice, the timing of the last dose of Apixaban before TAVR should be carefully planned to minimize the risk of bleeding while also considering the patient's individual risk factors for thromboembolism. For most patients with normal renal function, holding Apixaban for 24 hours before the procedure is likely sufficient 1. However, for patients with impaired renal function, a longer period of drug discontinuation may be necessary to ensure that the anticoagulant effect is adequately reversed 1.
From the FDA Drug Label
Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding The recommended duration to hold Apixaban (Eliquis) prior to Transcatheter Aortic Valve Replacement (TAVR), which is considered a procedure with a high risk of bleeding, is at least 48 hours 2.
From the Research
Apixaban and TAVR Procedure
- The recommended duration to hold Apixaban (Eliquis) prior to Transcatheter Aortic Valve Replacement (TAVR) is not directly stated in the provided studies.
- However, study 3 mentions that Apixaban, a non-vitamin K direct anticoagulant (NOAC), was shown to be superior to VKA and superior to aspirin to prevent cardioembolic stroke in non-valvular atrial fibrillation, and it may have the potential to reduce TAVR-related thrombotic complications.
- The ATLANTIS trial, mentioned in study 3, compares standard of care versus an apixaban-based strategy after successful TAVR, but it does not provide information on the duration to hold Apixaban prior to the procedure.
Anticoagulation Management in TAVR
- Study 4 discusses the use of bivalirudin versus heparin as anticoagulant agents during TAVR procedures, but it does not provide information on the management of Apixaban.
- Study 5 mentions that current guidelines recommend a three- to six-months dual antiplatelet therapy (DAPT) in patients undergoing TAVR, but it does not discuss the use of Apixaban or its duration prior to the procedure.
- Study 6 and 7 do not provide relevant information on the management of Apixaban prior to TAVR.
Conclusion on Available Evidence
- There are no research papers among the provided studies that directly assist in answering the question about the recommended duration to hold Apixaban prior to TAVR.